Behavior problems in children before first recognized seizures.

OBJECTIVE: It is not known when behavior problems begin in children with epilepsy. The purposes of this study were to: 1) describe the rates of behavior problems in children before their first recognized seizure, 2) determine the differences in behavior problems between children with a first recognized seizure and their healthy siblings, and 3) identify the seizure variables early in the course of the condition that are associated with behavior problems before the first recognized seizure. METHODS: The sample was 224 children (4-14 years old) with a first recognized seizure and their 135 healthy siblings. As part of a larger study, computer-assisted structured telephone interviews were conducted with mothers to measure child and sibling behavior problems. Behavior problems were measured using the Child Behavior Checklist. Frequencies, t tests, correlational analysis, and multiple regression were used to analyze data. RESULTS: Higher than expected rates of behavior problems in the 6 months before the first recognized seizure were found in the total seizure sample, with 32.1% being in the clinical or at-risk range. Rates were highest in children who had previous events that were probably seizures, with 39.5% in the clinical or at-risk range. Children with seizures had significantly higher Total, Internalizing, Attention, Thought, and Somatic Complaints problem scores than their nearest-in-age healthy siblings. Within the seizure sample, variables significantly associated with behavior problems after adjusting for research site, child sex, child age, and socioeconomic status (as represented by primary caregiver's education) were interactions of previously unrecognized seizures with gender and epilepsy syndrome/type of seizures. CONCLUSIONS: Children with previously unrecognized seizures are already at increased risk for behavior problems at the time of their first recognized seizure. These findings are consistent with the hypothesis that in some children, epilepsy is a pervasive condition that includes both seizures and behavioral problems.

Childhood epilepsy and asthma: changes in behavior problems related to gender and change in condition severity.

PURPOSE: We conducted a 4-year follow-up study of behavior problems in children with either epilepsy (n = 115) or asthma (n = 105) to identify changes in behavior problems as they were related to gender and change in condition severity. All children were between ages 8 and 13 years and had been diagnosed with their respective conditions for >/=1 year at entry into the study. METHODS: Behavior problems were measured by using the mother's rating on the Child Behavior Checklist. Baseline and follow-up behavior problem scores were examined to see if significant changes occurred over the observation period of the study. To explore change in behavior based on condition severity, each child was placed into "low" and "high" condition severity groups at each time, resulting in four groups: low/low, low/high, high/low, or high/high. There were too few cases in the low/high group to be included in some analyses. Data were analyzed by using analysis of covariance with adjustment for baseline behaviors, age, and age of onset. RESULTS: Within both samples, there was a significant improvement over time for the Total Behavior Problems and Internalizing Problems scores (p

Longitudinal study of adaptation to the stress of bone marrow transplantation.

PURPOSE: This prospective longitudinal study of adaptation to bone marrow transplantation (BMT) addressed three questions: (1) When during BMT do individuals experience the greatest distress? (2) What factors are associated with this distress? (3) Are there variables that could be potential clinical indicators of persons in greatest need of preventive intervention? PATIENTS AND METHODS: One hundred one participants undergoing either an autologous or allogeneic BMT completed questionnaires before hospitalization, before bone marrow infusion, 7 days and 14 days after transplantation, and then 1 month, 3 months, and 12 months after hospitalization. Adaptation was indicated by the degree of emotional distress. Independent variables were personal control, social support from specific sources, cognitive response, self-perception, and coping strategies, controlling for symptomatology. RESULTS: The greatest emotional distress occurred after admission to the hospital and before the bone marrow infusion. Anxiety and depression decreased 1 week after the transplant, although symptomatology increased during this time. The periods of least emotional distress were 3 months and 1 year after transplantation. Factors that accounted for the greatest variance in emotional distress/adaptation were the degree of emotional distress at baseline, personal control, cognitive response, and symptomatology. CONCLUSION: According to this longitudinal study, which includes pretransplant data, data from in-hospital transplantation, and posttransplant data, (1) psychosocial vulnerability of these BMT recipients was greatest during hospitalization before the transplant, (2) perceived personal control may be a potential indicator of vulnerability to secondary psychosocial morbidity, and (3) the demonstrated significance of psychosocial well-being before BMT indicates the importance of obtaining prospective data for both research and clinical purposes.

Factors associated with self-concept in children with asthma.

PURPOSE: To investigate the relationship of demographic asthma, family, and child factors with self-concept in children with asthma. METHODS: Data were collected twice approximately 4 years apart from both the affected children and their mothers (N = 134) via interviews and self-report questionnaire. FINDINGS: Children who demonstrated more negative attitudes toward their illness, had less satisfaction with family relationships, and used more negative coping behaviors had the poorest self-concepts. Over time, the greatest improvement in self-concept occurred in children whose attitudes and satisfaction with family relationships improved and whose use of negative coping behaviors decreased. CONCLUSIONS: Results suggest that some children with asthma, especially girls with severe asthma, appear to be at risk for poor self-concept.

Symptoms of depression in adolescents with epilepsy.

OBJECTIVE: To identify factors related to symptoms of depression in a sample of adolescents with epilepsy. METHOD: Cross-sectional data were collected on 115 adolescents aged 12 to 16 years who had epilepsy. Demographic (age, gender), seizure (severity, age of onset), family (stress, resources, relationships), mother (perceptions of stigma, depression), and child (attitude toward epilepsy, satisfaction with family relationships, coping, perceptions of control) variables were assessed by questionnaire and standardized scales. Depression was measured by the Children's Depression Inventory and the Anxiety/Depression subscale of the Youth Self-Report. Data were analyzed by using multiple regression with depression as the dependent variable. RESULTS: In this sample, 23% of subjects had symptoms of depression. Significant predictors of depression as measured by the Children's Depression Inventory (R2 = 0.53) were youth's attitude toward epilepsy, youth satisfaction with family relationships, and unknown locus of control or external locus of control for socially powerful others. CONCLUSIONS: Adolescents' attitudes, attributions, and satisfaction with family relationships are related to depression and should be assessed in the clinical setting. The relationship between locus of control and depression fits the learned helplessness model of depression and suggests the need for interventions to promote an internal locus of control in adolescents with epilepsy.

Does academic achievement in children with epilepsy change over time?

A 4-year follow-up study of academic achievement in children aged between 11 and 17 years with epilepsy or asthma was carried out to identify differences between the two samples and to identify change in achievement over time. Differences based on sex and seizure severity also were explored. There were 98 subjects in the group with epilepsy and 96 subjects in the group with asthma. Academic achievement in five areas (Composite, Reading, Mathematics, Language, and Vocabulary) was measured using school-administered group test scores. To explore change over time in condition severity, each child was categorized as having a low or high condition severity at baseline (time I) and again 4 years later, resulting in four groups: low-low, low-high, high-low, and high-high. There were too few cases in the low-high group to be included in the analyses. Data were processed using analysis of covariance (ANCOVA), intraclass correlation coefficients, and paired t tests. At follow-up the children with epilepsy continued to perform significantly worse in all five achievement areas than the children with asthma. Children with either inactive or low-severity epilepsy had mean scores comparable to national norms; those with high seizure severity had mean scores ranging from 3 to 5 points below national norms. No changes were found in academic achievement over time for either sample, even among those whose conditions improved. Although boys with high-severity epilepsy continued to have the lowest achievement scores, there was no trend for them to decline in achievement over time.

Cost of hospitalizations for heart failure: sodium retention versus other decompensating factors.

OBJECTIVE: To determine the cost of heart failure-related hospital admissions and to compare the cost of admissions for sodium retention with the cost of admissions for other decompensating factors. DESIGN: Retrospective, non-experimental, cost analysis. SETTING: Midwestern university-affiliated, tertiary care, medical center. SAMPLE: Two hundred seven heart failure-related admissions, 117 (57%) of which were for sodium retention leading to volume overload. OUTCOME MEASURES: Cost of hospitalization. PROCEDURE: Data obtained from the patient and financial records of patients hospitalized for heart failure in 1992 were analyzed using the ratio of cost-to-charge accounting procedure. RESULTS: The total cost was $2,442,720 for the 207 heart failure-related admissions; the average cost was $12,400 per admission. Approximately half of the cost of the hospitalizations was expended in the 4 cost centers comprising routine and critical care services, which incorporate room charges and nursing care. Another one third of the cost was for supplies, medications, and laboratory tests. Admissions as a result of sodium retention had lower costs than admissions as a result of other factors. CONCLUSION: The cost of hospitalization for heart failure is high. Routine services, supplies, medications, and laboratory tests used by these patients contribute to the high cost of care. Improved outpatient management strategies are necessary to reduce hospital admissions as a result of sodium retention.

Quality of life in women with heart failure.

Persons with heart failure (HF) experience impaired quality of life (QOL). However, the majority of research conducted on QOL in persons with HF has been with men. The purpose of this descriptive pilot study was to describe the impact of symptoms of HF and examine the relationships among symptom impact, perceived health status, perceived social support, and overall QOL in 30 women who had recently been hospitalized for HF. The women reported high physical symptom impact, poor perceived physical health status, and impaired QOL. Physical symptom impact, perceived physical health status, and QOL were moderately to highly correlated with one another. Perceived social support was significantly, though not strongly, correlated with physical symptom impact. Emotional symptom impact and mental health status were significantly and negatively correlated with each other but were not significantly correlated with QOL. In this group of 30 chronically ill women, QOL was lower in those women who reported greater physical symptom impact and poorer perceptions of their physical health status.

Academic achievement in children with epilepsy or asthma.

The purposes of the study were to compare academic achievement between children with epilepsy and those with asthma and to identify child perception, school adaptive functioning, and condition severity factors related to academic achievement. Subjects were 225 children (117 with epilepsy and 108 with asthma) aged between 8 and 12 years. Academic achievement was measured using school-administered group tests. Self-report questionnaires were used to measure child attitudes and school self-concept. Teachers rated school adaptive functioning. Data were analyzed using ANCOVA and multiple regression. Children with epilepsy had significantly lower achievement scores than children with asthma. Boys with severe epilepsy were most at risk for underachievement. Factors related to poor academic achievement in both samples were: high condition severity, negative attitudes, and lower school adaptive functioning scores. Less variance was accounted for in the model for epilepsy (R2=0.25) than for asthma (R2=0.36). Boys with high seizure severity were most at risk for achievement-related problems. Future research in epilepsy should consider additional factors in the model predicting academic achievement.

Characterization of the precipitants of hospitalization for heart failure decompensation.

BACKGROUND: The model for management of patients with heart failure may be a key determinant of morbidity and quality of life. Development of a better management strategy for these patients requires determination of the reasons for decompensation that leads to hospitalization. OBJECTIVES: To ascertain and rank the principal reasons for hospitalization of patients who have heart failure. METHODS: Retrospective audit of all 1992 admissions (N = 1031; 691 patients) coded for heart failure at a Veterans Affairs medical center and a tertiary care university medical center. RESULTS: The diagnosis of heart failure was verified by preset criteria in 72% of the patients. Of the 496 patients with documented heart failure, worsening heart failure was a main reason for admission in 390 (79%). Despite different socioeconomic backgrounds, excessive sodium retention was the leading factor (55%) associated with decompensation in patients at both institutions. Other factors precipitated admission much less often. CONCLUSIONS: Many hospitalizations for heart failure might be avoided by case management directed at lessening sodium overload. Increased use of medications known to be effective in persons with heart failure (angiotensin-converting enzyme inhibitors, digoxin, and adequate diuretic therapy) might reduce the likelihood of decompensation. Implementation of behavioral interventions to assist patients with self-monitoring signs of sodium retention and to improve compliance with medications and dietary sodium restrictions are strategies for further reducing the risk of decompensation.

Behaviour problems in children with new-onset epilepsy.

Behaviour problems are common in children with epilepsy and it is not known when these problems begin. Some suggest that behaviour problems are caused by a neurological condition that also causes the seizures. Behaviour problems were investigated in 42 youths (23 girls and 19 boys) over a 4-month period beginning at the time of the initial seizure. Subjects were aged 4-15 years (mean, M = 8.4). Approximately 57% had partial seizure(s) and 43% had generalized seizure(s). The large majority (71%) were diagnosed with epilepsy. As a part of a larger study, parents rated their children's behaviour on the Child Behaviour Checklist immediately prior to the first seizure (time 1), and at 4 months after the first seizure (time 2). Seizure severity was rated as follows: high = 20%, moderate = 39%, and low = 41%. At time 1, 24% already had behaviour problems. Behaviour problems significantly decreased from time 1 to time 2 (P < 0.001) for the whole group. Within the epilepsy group (n = 40), differences were found in behaviour problems based on seizure severity from time 1 to time 2 as follows: low, time 1: M = 55, time 2: M = 45; moderate, time 1: M = 55, time 2: M = 51; and high, time 1: M = 61, time 2: M = 55. Results indicate that children should be assessed for behaviour problems at the time of the first seizure.

Beliefs about medication and dietary compliance in people with heart failure: an instrument development study.

BACKGROUND: Sodium retention is often a precursor to hospitalization in people with heart failure (HF). Lack of compliance with medications and with dietary sodium restrictions affects sodium retention. OBJECTIVES: The purpose of this study was to evaluate the reliability and validity of the Beliefs about Medication Compliance Scale and the Beliefs about Dietary Compliance Scale. METHODS: The Beliefs about Medication Compliance Scale and the Beliefs about Dietary Compliance Scale are instruments we developed specifically to measure beliefs about compliance with behaviors that affect sodium retention in persons with HF. The scales, based on the Health Belief Model, were designed from a review of literature and from self-reports of people with HF. A convenience sample of 101 people with HF completed the scales. RESULTS: Internal consistency reliability was satisfactory. Factor analysis provided initial support for construct validity of the scales. CONCLUSIONS: Future testing of the scales is needed in more diverse populations. The scales can then be used to test interventions tailored to individual subjects' beliefs about compliance.

Psychosocial variables and hospitalization in persons with chronic heart failure.

Persons with chronic heart failure (HF) must cope not only with the physical impairment of their disease but with the associated emotional distress. The primary purpose of this prospective study was to examine whether the psychosocial variables of symptom impact measured at baseline--health perception, social support and coping--differed between a group of adults with chronic HF who were hospitalized and a group who were not hospitalized during the following six months of the study. A secondary purpose was to examine indices of left ventricular dysfunction that might influence hospitalization. Within the six-month period following baseline data collection, 23 of 62 (37%) patients who completed the study were hospitalized at least once for problems pertaining to HF. Patients in the hospitalized group reported significantly more baseline symptom impact, particularly in the areas of emotional symptoms and deficits of attention and memory. Social support and coping did not differ significantly between hospitalized and nonhospitalized patients. Extent of myocardial dysfunction, age and demographic variables were not significantly different between the two groups. Heart failure decompensation requiring inpatient management was presaged by increased anxiety and disorders of mentation, suggesting that health care providers need to be sensitive to these reported symptoms and their impact, because they might be clues to impending hospitalization.

Adolescents with active or inactive epilepsy or asthma: a comparison of quality of life.

PURPOSE: We compared quality of life (QOL) in youth with inactive or active epilepsy with that of a similar sample of youth with asthma. We explored 19 different dimensions in three domains (psychological, social, and school) and also determined differences related to illness severity and gender. METHODS: Subjects were 228 adolescents (117 with epilepsy and 111 with asthma). Data were collected from clinic records and from the adolescents, their mothers, and their teachers through questionnaires and structured interviews. Data were analyzed by analysis of covariance. RESULTS: The analysis with all 19 QOL variables indicated a significant difference between the total asthma and the total epilepsy samples (multivariate F = 3.36, p = 0.0001). Further evaluation reflected differences between the epilepsy group and the asthma group on 13 of the 19 QOL variables. When active and inactive epilepsy and asthma groups were compared, youth with active epilepsy were faring worse than all other groups in 10 areas. Moreover, youth with inactive epilepsy were faring worse than those with inactive asthma in four areas. Illness severity and sex differences were more strongly related to QOL in the epilepsy sample than in the asthma sample. Sex-severity interactions suggested that girls with high seizure severity were most at risk for QOL problems. CONCLUSIONS: Youth with active epilepsy generally had the poorest QOL. Severe seizures and female sex were associated with more problems. Sex-severity interactions should be explored in future research.

Risk factors for nonelective hospital readmissions.

We previously reported a predictive model that identified potentially modifiable risk factors for nonelective readmission to a county hospital. The objectives of this study were to determine if those risk factors were generalizable to a different population. We found that the previously reported risk factors were generalizable, and other potentially modifiable risk factors were identified in this population of veterans. However, further research is needed to establish whether or not the risk factors can be modified and whether or not modification improves outcomes.

Behavioural adjustment and parental stress associated with closed head injury in children.

Parental stress and parental perception of children's behavioural problems were determined for 25 caretakers of children with closed head injury. Compared to normative samples a greater proportion of parents in this study were more stressed, and thought that their children were more behaviourally impaired. In contrast to previous studies, injury severity was not related to behavioural impairment. Parental stress was related to perceived behavioural impairment for the brain-injured sample. When compared to low-stressed parents (n = 14), high-stressed parents (n = 11) described their children as more aggressive and with more thought disorders and attention problems. Time since injury, age at injury, number of siblings, and mother's age were not different between the high- and low-stressed groups. Low income and less education were associated with the high stress levels in these parents. Test-retest data showed that, over time, parents perceived their brain-injured children as less behaviourally impaired.

Pubertal staging in boys.

To determine the earliest signs of pubertal maturation, we followed 515 boys, aged 10 to 15 years at intake, every 6 months for 3 years. Changes in age, height, weight, body mass index, and serum levels of sex steroid hormones were significantly related to pubertal stage (PS). The earliest clinical stage of pubertal maturation, designated PS2a, was represented by the absence of public hair and a testicular volume 3 cc or greater; 6 months later, further maturation had occurred in 82% of these boys. Inclusion of PS2a as the earliest stage of puberty may help allay concerns about boys with perceived delayed maturation, and may allow more precise definition of early puberty.

Definition and application of the discretionary screening indicators according to the National Cholesterol Education Program for Children and Adolescents.

OBJECTIVES: (1) To propose definitions for the discretionary screening indicators described by the National Cholesterol Education Program for Children and Adolescents (NCEP-Peds); (2) to examine the relative prevalence of major screening indicators (family history of premature heart disease and parental plasma cholesterol concentration > or = 6.21 mmol/L (240 mg/dl)) and discretionary screening indicators (excessive consumption of fat or cholesterol or both, smoking, diabetes, hypertension, and steroid use) in a family population; and (3) to evaluate the relative value of the major and the discretionary indicators in detecting high serum levels of low-density lipoprotein-cholesterol (LDL-C) (> or = 3.36 mmol/L (> or = 130 mg/dl)). DESIGN: Control cohort from a case-control study. SETTING: Lipid research clinic. PARTICIPANTS: White children and adolescents < 20 years of age from 232 nuclear families who participated in the Cincinnati Myocardial Infarction Hormone Study. MAIN OUTCOME MEASURES: (1) Number of children who have major and discretionary screening indicators; (2) sensitivity and specificity of the major and the discretionary screening indicators in identifying children with LDL-C concentrations > 3.36 mmol/L (130 mg/dl) (high LDL-C). RESULTS: With cutoff points of the 90th percentile for blood pressure, the 85th percentile for obesity, and the 80th percentile for dietary fat and cholesterol, and self-report for diabetes, smoking, and corticosteroid use, 54% of the 232 children in the cohort had one or more discretionary indicators. Additionally, applying the major screening indicators raised the percentage of children identified to 74%. Twenty-eight percent had both major and discretionary indicators. Having a discretionary screening indicator did not increase the probability of having a major indicator. Applying both discretionary and major screening indicators to the cohort identified 96% of the children who had a high concentration of LDL-C; 30% of the children with high LDL-C levels were discovered solely by the discretionary indicators. Similar sensitivity and specificity were noted between the major and the discretionary indicators. Children with high LDL-C concentrations were more likely to have multiple screening indicators. CONCLUSION: Discretionary and major screening indicators suggested by the National Cholesterol Education Program for Children and Adolescents identify different subsets of children at risk of having premature cardiovascular disease. Both major and discretionary indicators contribute to the identification of children with high LDL-C concentrations.

Effect of premature myocardial infarction in men on the eating habits of spouses and offspring.

OBJECTIVE: To investigate whether family members comply with a healthier diet after the father has had a myocardial infarction. DESIGN: Cohort study with administration of a dietary history questionnaire. SETTING: Outpatient lipid research clinic, Cincinnati, Ohio. SUBJECTS: Male subjects (referred to as father) who had had myocardial infarction before age 56 years were recruited along with their spouse and at least one offspring (myocardial infarction [MI] group; n = 136). Control families (comparison group; n = 237) were also recruited. STATISTICAL ANALYSES: The t test, analysis of covariance, analysis of variance, least-squares means, chi 2, and Kruskal-Wallis. RESULTS: Significant differences in dietary intake were found for percentage of energy from total and saturated fat (P < .0001), ratio of polyunsaturated fat to saturated fat (P:S ratio) (P < .0001), and cholesterol intake (P = .001) between fathers in the MI and comparison groups. The fathers in the MI group consumed 4.5% and 2.6% less energy from total and saturated fat, respectively, and less cholesterol (135 vs 151 mg/1,000 kcal) and demonstrated a higher P:S ratio (0.76 vs 0.62) than the fathers in the comparison group. Spouses in the MI group consumed less total energy (P = .02) and less energy from fat and saturated fat than spouses in the comparison group (P = .04 and P = .004, respectively). When spouses were grouped by time since the father's myocardial infarction, no differences were found in energy from saturated fat intake between the comparison population and those spouses 3 years or more after the myocardial infarction. The diet of the offspring in the MI group closely resembled that of the offspring in the comparison group. CONCLUSIONS/APPLICATIONS: Fathers who had experienced a myocardial infarction complied with a diet lower in fat and cholesterol than did fathers in a control comparison group. Spouses only complied with an improved diet for an initial period after the cardiac event. The cardiac event demonstrated little to no effect on the diet of the offspring. Offspring who have a high risk for cardiovascular disease, as well as the parents, need to be educated about the importance of establishing and maintaining a proper dietary regimen.

Acne vulgaris in premenarchal girls. An early sign of puberty associated with rising levels of dehydroepiandrosterone.

BACKGROUND: This study examined the relationships of pubertal maturation and sex steroid hormones to the development of acne in young girls. Black (n = 317) and white (n = 306) premenarchal girls with a mean age of 9.97 +/- 0.62 years were evaluated for acne prevalence and severity, pubic hair and areolar maturation, and sex steroid hormone levels. RESULTS: Overall, 77.8% of the girls had some acne; of the whole group, 48.3% had only comedonal acne, 2.2% had only inflammatory acne, and 27.3% had both types. Although black girls matured at an earlier age than white girls, racial differences in acne were minimal when adjusted for pubertal maturation. Acne increased with advancing maturation; at Tanner pubic hair stages 1, 2, and 3, the prevalence of acne rose from 73.1% to 84.0% and to 90.6%, respectively. Acne lesion counts at seven facial locations revealed a predominance of midfacial acne on the middle aspect of the forehead, nose, and chin. Sex steroid hormone levels measured in 365 of the girls were found to increase significantly during maturation from prepuberty to early puberty. Testosterone-estrogen-binding globulin and the ratio of testosterone to estradiol decreased. In 118 prepubertal girls, estradiol, total and free testosterone, progesterone, testosterone to estradiol ratio, and testosterone-estrogen-binding globulin levels were no different whether in subjects with acne or without acne. However, the level of dehydroepiandrosterone sulfate, an androgen of adrenal origin, was significantly higher in prepubertal girls with acne. CONCLUSION: Acne, especially the comedonal type, can be the first sign of pubertal maturation in girls, even preceding pubic hair and areolar development. Concentration of dehydroepiandrosterone sulfate is significantly and specifically associated with the initiation of acne in young girls.