Bristol Stool Form Scale reliability and agreement decreases when determining Rome III stool form designations.

BACKGROUND: Rater reproducibility of the Bristol Stool Form Scale (BSFS), which categorizes stools into one of seven types, is unknown. We sought to determine reliability and agreement by individual stool type and when responses are categorized by Rome III clinical designation as normal or abnormal (constipation or diarrhea). METHODS: Thirty-four gastroenterology providers from three institutions rated 35 stool photographs using the BSFS. Twenty rerated the photographs. KEY RESULTS: 1190 individual stool type ratings were completed. Though only four photographs had absolute agreement (all Type 1 or Type 7), general agreement was high with 1132 (95.1%) of ratings being within one category type of the modal rating. Inter-rater and intra-rater reliability of the BSFS by individual stool type was excellent with intraclass correlations of 0.88 (95% CI: 0.86-0.90, p < 0.001) and 0.89 (95% CI: 0.86-0.91, p < 0.001), respectively. However, agreement decreased when using Rome III designations with 13 (37%) photographs having significantly diverging classifications (semi-interquartile range = 0.5). These 13 photographs were rated by the majority of raters as either type 2 vs type 3 or type 5 vs type 6 stools, representing the boundaries of normal vs abnormal stools. Inter-rater and intra-rater reliability of the BSFS by Rome III clinical categorization decreased with intraclass correlations of 0.75 (95% CI: 0.69-0.81, p < 0.001) and 0.65 (95% CI: 0.49-0.81, p < 0.001), respectively. CONCLUSIONS & INFERENCES: The Bristol Stool Form Scale has excellent reliability and agreement when used to rate individual stool type by raters. However, BSFS reliability and agreement decreases when determining Rome III stool form categories.

Agreement between prospective diary data and retrospective questionnaire report of abdominal pain and stooling symptoms in children with irritable bowel syndrome.

BACKGROUND: In functional gastrointestinal disorders, patient recall of symptoms drives diagnostic decisions and evaluation of treatment response, and research conclusions about potential treatments. In pediatrics, parent report also impacts assessment and care. Hence, identifying methods for accurately capturing patient and parent report of irritable bowel syndrome (IBS) symptoms is important. This study evaluated correspondence between retrospective questionnaire (parent and child report) and prospective diary data for children and adolescents with IBS. METHODS: Participants included 50 children/adolescents with IBS per Rome III criteria. Children completed a 2-week pain and stool diary. Children and parents subsequently completed a 2-week recall questionnaire, reporting number of pain days, maximum pain, days without bowel movement, and days with diarrhea during the diary interval. Intraclass correlation coefficients and Bland-Altman plots assessed agreement. KEY RESULTS: For pain and days without bowel movement, overall agreement between child recall questionnaire and child diary was strong, although under conditions likely to facilitate agreement and with individual variation observed. Parent recall and child diary were less concordant, and agreement about diarrhea was poor for parent and child. Age did not significantly correlate with agreement. CONCLUSIONS & INFERENCES: Child questionnaire with short recall interval may be a reasonable approximation for diary data, although this varies by individual and replication/investigation of lengthier recall are needed. Relying on parent questionnaire does not appear a suitable proxy, and recall of stool form by both parent and child appears more problematic. These results combined with existing literature support use of diary data whenever possible.

The interpretation of Rome III criteria and method of assessment affect the irritable bowel syndrome classification of children.

BACKGROUND: Paediatric classification of irritable bowel syndrome (IBS) is complicated by the potential discrepancy between parent and child report and by the interpretation of pain-stool relations in the Rome III classification system. AIM: To compare IBS classification by diary and by child and parent respondents. METHODS: Children (ages 7-10 years, n = 90) with recurrent abdominal pain and their parents completed IBS symptom questionnaires and 2-week pain and stool diaries. Diaries were coded with two algorithms, one defining stool changes individually and one defining changes normatively. Proportions of dichotomous classifications (IBS vs. not IBS) between pairs of classification methods/respondents were evaluated using Chi-squared tests (χ²) to determine whether coding methods were significantly related, the degree of inclusiveness, and whether differences in classification were randomly distributed. RESULTS: Individual and normative diary classifications were congruent in 62% of cases, but the individual method classified more children with IBS, 53% vs. 18%. Parent and child questionnaire reports were not correlated. The normative diary classifications and parent questionnaire were the most congruent pair of methods (76% of cases). CONCLUSIONS: Poor congruence among methods suggests that Rome III IBS criteria need better specification, and efforts to improve parent-child agreement are necessary.

Development of an expert system knowledge base: a novel approach to promote guideline congruent asthma care.

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

Watch, Discover, Think, and Act: a model for patient education program development.

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.

Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children.

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

Long-term adjustment issues in patients with exstrophy.

PURPOSE: We explored the psychological adjustment of children with bladder or cloacal exstrophy. MATERIALS AND METHODS: We assessed 29 subjects with a mean age plus or minus standard deviation of 7.8 +/- 3.97 years using age appropriate standard psychological instruments. Psychological adjustment scores in the exstrophy group were compared to the norms of the various instruments. Subjects were divided into dichotomous groups according to several medical and demographic factors. For each factor the differences between the means of the 2 groups on the outcome variables were calculated using a t test. RESULTS: Children with exstrophy perceived their appearance more positively than the norm. Older children performed more poorly than younger children in adaptive behavior, specifically in skills related to functioning in school. Children who achieved continence after age 4 years were more likely to have problems with acting out behavior. There were no differences in adjustment in boys versus girls, bladder versus cloacal exstrophy, type of continence strategy or gender reassignment versus no reassignment. CONCLUSIONS: Children with exstrophy did not have clinical psychopathology. Differences existed in adaptive and acting out behavior rather than depression or anxiety, suggesting that improved outcomes may be achieved through a focus on normal adaptation rather than on potential psychological distress.

Clinical psychology in the management of pediatric skin disease.

The role of psychological factors in certain dermatological conditions is not disputed; however, these processes have been much more thoroughly explored in adult populations than in pediatric populations. Therefore, this article reviews relevant adult and child studies. This article explores three aspects of psychological functioning as they relate to dermatological conditions and their treatment, specifically stress and emotional regulation, behavioral and environmental issues, and compliance. The goal of this article is to give the practicing dermatologist a working overview of psychological factors in pediatric skin disease which will facilitate good communication with families around these issues and referral for adjunctive psychological treatment as needed.

Neuropsychologic impact of facial deformities in children. Neurodevelopmental role of the face in communication and bonding.

The face is the primary tool of human communication. In early childhood, the face plays a crucial role in bonding and attachment. Severe craniofacial problems may alter bonding and attachment, thereby resulting in future risk for emotional, behavioral, and social problems. Clinical and research findings, while incomplete, suggest that this is the case. This conceptual understanding of the key role of face-to-face communication in early childhood provides a compelling rationale for early repair of craniofacial deformations.

Self-management of cystic fibrosis: short-term outcomes of the Cystic Fibrosis Family Education Program.

This study tested the efficacy of the Cystic Fibrosis Family Education Program, a cystic fibrosis self-management program, on improving participants' knowledge, self-efficacy, self-management behavior, health, and quality of life. A quasi-experimental pretest-posttest nonequivalent comparison group design was employed. Participants made up 104 patient-primary caregiver dyads from the intervention site cystic fibrosis center and 95 from the usual care comparison center. The intervention, a self-paced print curriculum based on social cognitive theory, targeted behavioral capability, self-efficacy, and outcome expectations and was implemented as an integral part of medical care. Parents, early childhood, middle childhood, and adolescents received separate materials on respiratory, nutrition and malabsorption, communication, and coping issues. Significant intervention effects were found on the knowledge scores for caregivers, adolescents, and children; caregiver and adolescent total self-management scores; Child Behavior Checklist total score; one parent coping scale score; the modified NIH score; NIH pulmonary factor 1; and the Brasfield total score. Significant interaction effects were evident in the self-efficacy scores for caregivers and children.

Parents of children with cancer: a longitudinal study of emotional distress, coping style, and marital adjustment two and twenty months after diagnosis.

Evaluated emotional distress, coping style, and marital adjustment in 84 parents (42 couples) of children with cancer 2 months after diagnosis and again about 20 months after diagnosis. As expected, mothers' mean state anxiety and trait anxiety scores decreased to near normal levels over time. Fathers' scores were lower initially and did not change. Neither mothers' nor fathers' mean marital adjustment scores changed over time. Marital adjustment at treatment follow-up was predicted by depression and the spouse's marital satisfaction in mothers, and depression, child health status, and spouse's marital satisfaction in fathers. In contrast to findings obtained 2 months after diagnosis, coping style was not related to marital adjustment at follow-up. Results are discussed in terms of possible gender differences in the role of social support in marital adjustment and the stability versus situational specificity of coping styles.

Self-management of cystic fibrosis: a structural model for educational and behavioral variables.

One hundred and ninety-nine patients and their primary caregivers at two metropolitan cystic fibrosis centers participated in a clinical trial to evaluate the effectiveness of a health education program designed to help improve self-management skills for the care of CF. The baseline data from the study was used to test a structural model that hypothesized the relationship between educational, behavioral, and health status variables. Controlling for the effects of all other variables, including demographic, self-efficacy (confidence in being able to perform a behavior) was the most important educational factor predicting self-management behavior for monitoring and treating respiratory problems. Knowledge about the management of CF was only related to the ability of caretakers to apply coping skills to problems associated with CF. The more caretakers reported performing monitoring behaviors the more likely they were to report performing self-management treatment behaviors. The findings suggest that educational interventions that focus on increased knowledge alone are not likely to be effective in improving self-management behavior for CF. Based on the structural model analyses, it is recommended that educational programs for CF patients and families address increased self-efficacy and improved monitoring skills to influence the improvement of self-management treatment for CF.

Performance objectives for the self-management of cystic fibrosis.

Performance objectives for the self-management of cystic fibrosis (CF) were developed and subjected to a two-stage content validation. A multidisciplinary team of health care professionals generated a list of 149 medical and adjustment performance objectives. Behaviors included monitoring symptoms and judging their significance, treating symptoms and communicating with health care providers about symptoms and treatment plans. In the first stage a panel of experts in the medical and behavioral aspects of CF rated each behavior. In general, the eleven panelists rated the 149 behaviors as somewhat important or important (mean 2.6, S.D. 0.17, on a 3-point scale). In the second stage, 84 of 155 CF center directors rated all behaviors as somewhat important or important (mean 2.9, S.D. 0.23). Specific behaviors related to medical regimens were more consistently rated as important than were those related to psychosocial adjustment. The performance objectives provide a framework for developing and evaluating health education programs for the self-management of CF in order to promote optimum health and adjustment.

Parents of children newly diagnosed with cancer: anxiety, coping, and marital distress.

Evaluated anxiety, approach-avoidance coping style, and marital distress in 134 parents of children with cancer shortly after diagnosis. Of the 67 marital pairs studied, approximately 25% of the mothers and 28% of the fathers reported significant marital distress. Regression analyses revealed that marital distress was predicted by a combination of general emotional distress, the discrepancy between the couple's state anxiety levels, and the couple's use of sensitizing coping strategies. Greater differences in anxiety levels between the parents and greater stimulus approach coping activity in the marriage were associated with greater reported marital distress.

Measuring self-efficacy expectations for the self-management of cystic fibrosis.

This research developed and determined the psychometric characteristics of a measure of self-efficacy expectations (a social cognitive theory construct) for the self-management of cystic fibrosis (CF). Items for the original instrument were sampled from 150 self-management performance objectives for CF that represented behaviors in eight domains of CF care, including aspects of medical care, coping, and communication. The instrument was administered to 199 parents of children and adolescents with CF from two CF centers. The findings support a multidimensional structure for self-efficacy consistent with the multiple types of behavior required for the management of a chronic illness such as CF. An alpha-factor analysis yielded solutions clearly reflecting five theorized aspects of self-management: medical judgment and communication, coping, family communication, compliance, and acceptance. The first factor of the caretaker's scale most closely represents the underlying conceptualization of self-management as requiring self-monitoring of health status and collaboration with the health care provider in making judgments about treatment. The unit weighted factors exhibited high internal consistencies (Cronbach's alpha-factors ranging from 0.73 to 0.88).