Paediatric antiepileptic polytherapy: systematic review of efficacy and neurobehavioural effects and a tertiary centre experience.

AIM: This paper presents the prevalence of antiepileptic polytherapy at a single tertiary institution and systematically reviews the evidence base for its efficacy and neurobehavioural safety in children. METHOD: Prevalence of antiepileptic polypharmacy was determined from pharmacy dispensing records at a paediatric tertiary hospital and neurobehavioural comorbidities quantified through casenote review; comparison is made with studies evaluating the neurobehavioural safety of antiepileptic polytherapy, identified via systematic literature review. RESULTS: Amongst 262 patients at the hospital, 117 (44.7%) were prescribed polytherapy; with patients having an intellectual disability statistically more likely to be prescribed polytherapy than those without (70.5% vs 40.6%; p < 0.0001). Systematic review identified no trials addressing the efficacy or neurobehavioural outcomes of polytherapy as a primary outcome. Several observational studies identified associations between polytherapy and neurobehavioural adverse outcomes such as anxiety and behavioural disturbance. Observational studies also suggest that a reduction in polytherapy load is generally not associated with worsening seizure control. CONCLUSION: Whilst antiepileptic polytherapy is common practice within paediatric epilepsy cohorts attending tertiary care institutions, evidence is lacking to support its efficacy. There are significant practical difficulties to undertaking randomised controlled trials within this population. Nonetheless, clinicians must consider that adverse neurobehavioural consequences of polytherapy might outweigh benefits to seizure control.

Restrained rehabilitation: an approach to children and adolescents with unexplained signs and symptoms.

The validation of treatment approaches for children and adolescents diagnosed with unexplained signs and symptoms is made difficult by the variety of clinical presentations and the different developmental levels of different patients. There is little evidence about what combination of approaches is most successful. This article uses what evidence is available to develop a coordinated multidisciplinary rehabilitation package that ensures consistency and can be evaluated. The package is organised around a psychologically informed physical rehabilitation programme. The need for coordination and a common approach between medical, allied health and psychological staff, and family is formally addressed. The approach is illustrated with a case study.

Health-service use by children with asthma over a 6-month period.

OBJECTIVES: The present study aims to describe the use of health services by children with asthma, and examine disease-specific, parental and sociodemographic variables associated with different levels of health-service utilization. METHODS: Parents of 135 children attending an emergency room (ER) completed questionnaires measuring the children's asthma symptoms, and sociodemographic and psychological variables. Parents were contacted monthly for 6 months to document the number of planned and unplanned visits to hospital and community health-care services for asthma. RESULTS: At least one further unplanned visit to the ER was made by 37% of children, while 62% made at least one unplanned visit to a general practitioner (GP). Fifty-five per cent made planned review visits to a GP, 30% to paediatricians and 5% to hospital clinics. After controlling for the level of asthma symptoms, parental anxiety and parental perceptions of children's vulnerability were associated with unplanned GP visits (P = 0.05 and P = 0.01, respectively); a planned review visit and the child being admitted to hospital for the index attack were associated with unplanned ER visits (P = 0.05 and P = 0.004, respectively). CONCLUSIONS: Children with asthma more frequently attend GP services than hospital services for both planned and unplanned asthma management. Different variables predict the unplanned use of GP and ER services. Understanding these differences is imperative if children and families are to make the most effective use of health services.

Hysteria. Pretending to be sick and its consequences.

Hysteria, as it involves the medical profession, is a form of sickness that is defined as being without disease or illness. This lack of a biomedical explanation has limited progress in its understanding. In this essay we propose that hysteria might be better thought of as a form of pretending, elaborated in transaction with the medical system. In medicine, to pretend usually means to deceive. From the perspective of play, however, pretend is a state more akin to acting, magic, belief, and hypnosis. We provide a number of reasons why sickness is an attractive focus for pretending. We show how enactments of sickness can be scripted by a group of involved persons, each contributing from their own perspective, as occurs in the parlour game of 'Consequences', except in hysteria the consequences are often dire.

Alcohol use by parents who present their child to a paediatric emergency department.

OBJECTIVES: Parental alcohol misuse exposes children to risk, but is poorly identified in paediatric settings. We aimed to (i) measure the alcohol use in parents of a sample of children attending emergency and (ii) assess the quality of documentation of this alcohol use by paediatric residents. METHOD: Parents of children presenting to the Emergency Department of a children's hospital were interviewed regarding their alcohol use, and each completed an AUDIT CORE questionnaire. The child's case notes were reviewed for documentation of parental alcohol use. RESULTS: One hundred and ninety-three parents were interviewed. Although per capita alcohol use for both sexes, and hazardous drinking for females were found to be significantly less than general population figures, rates of hazardous drinking were high for fathers. Yet only 1% of case notes reviewed contained any documentation of parental alcohol use. CONCLUSION: This small study suggests that although average alcohol intake amongst parents presenting their children to a paediatric emergency department may be lower than for the general population, there is a significant prevalence of undetected hazardous drinking amongst parents.

Shortcomings in psychosocial history taking in a paediatric emergency department.

OBJECTIVE: To assess the quality of documentation of the psychosocial history taken from parents who repeatedly bring their infants and young children to an emergency department. METHODOLOGY: We prepared a list of 26 psychosocial items, indicated by the literature to be important elements of a history taken in this setting. We then reviewed subjects' casenotes, and compared each history to this ideal list. PARTICIPANTS/SETTING: Case note review of 104 children under 2 years who had presented to a paediatric emergency department at least five times in 1 year. RESULTS: Documentation of psychosocial history for these subjects was very poor, with a mean of only 5 of the 26 possible psychosocial items mentioned per set of casenotes. The majority of records lacked important information, including basic demographic data. CONCLUSIONS: We canvass possible reasons for poor psychosocial history taking, and argue for changes in medical education, the development of techniques to efficiently identify at risk children and families, and improved resources for referral.

Munchausen syndrome by proxy. Child abuse in the medical system.

Munchausen syndrome by proxy often is managed differently from other forms of child maltreatment, although it is differentiated from them only by the active engagement with the medical profession in the production of morbidity. We suggest a more rigorous approach to Munchausen syndrome by proxy, with explicit acknowledgement that it is abuse and that the medical system is critical to its genesis. This leads us to question the broadness with which the label is applied (eg, in cases of imposed upper airway obstruction) and to argue for management strategies closer to those accepted for other forms of child maltreatment.

Some reasons for concern about attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is not a disease. The symptoms of its three dimensions (activity, attention and impulsivity) are normally distributed in the population, with an arbitrary level of symptoms being designated pathological. The presence of the ADHD cluster is never grounds for any positive diagnosis; it is an indication for further assessment. Positive response to stimulants is not specific to the ADHD population, and is no way diagnostic.

Projective identification in general psychiatry.

Projective identification is a psychoanalytic concept encompassing functions of defence and communication. It is invaluable in a variety of settings in general psychiatry, including patient assessment, ward management and work with families.

Psychotherapeutic implications of severe physical disability.

Some effects of physical disability on psychological functioning are reviewed. Special roles are proposed for fantasy and therapist counter-transference in psychotherapy with physically disabled people. This report of the treatment of a man with severe cerebral palsy has implications for the physical and psychological management of the disabled.