Deviation from developmentally appropriate self-care autonomy. Association with diabetes outcomes.

OBJECTIVE: Treatment of IDDM in youth emphasized balancing children's self-care autonomy with their psychological maturity. However, few data exist to guide clinicians or parents, and little is known about correlates of deviations from this ideal. RESEARCH DESIGN AND METHODS: In this cross-sectional study, IDDM self-care autonomy of 100 youth was assessed using two well-validated measures. Three measures of psychological maturity (cognitive function, social-cognitive development, and academic achievement) were also collected for each child. Composite indexes of self-care autonomy and of psychological maturity were formed, and the ratio of the self-care autonomy index to the psychological maturity index quantified each child's deviation from developmentally appropriate IDDM self-care autonomy. Based on these scores, participants were categorized as exhibiting constrained (lower tertile), appropriate (middle tertile), or excessive (higher tertile) self-care autonomy. Between-group differences in treatment adherence, diabetes knowledge, glycemic control, and hospitalization rates were explored. RESULTS: Analysis of covariance controlling for age revealed that the excessive self-care autonomy group demonstrated less favorable treatment adherence, diabetes knowledge, hospitalization rates, and, marginally, glycemic control. Excessive self-care autonomy increased with age and was less common among intact two-parent families but was unrelated to other demographic factors. CONCLUSIONS: The findings indicate caution about encouragement of maximal self-care autonomy among youth with IDDM and suggest that families who succeed in maintaining parental involvement in diabetes management may have better outcomes.

Effect of parental acceptance or rejection of a proposed aversive intervention on treatment acceptability.

Effects of parental acceptance or rejection of a proposed aversive behavioral intervention on treatment acceptability ratings were investigated. Results suggest that parental acceptance or rejection of the proposed intervention significantly affected treatment acceptability ratings. The issue of a client's right to effective treatment versus the right to be free of a restrictive or aversive intervention was the dominant issue for judges. Results were discussed in terms of the usefulness of treatment acceptability ratings in treatment decision-making.

Sedation with meperidine and midazolam in pediatric patients undergoing endoscopy.

We conducted a randomized, double-blind trial evaluating the efficacy and safety of meperidine 2 mg.kg-1 (M) and meperidine 2 mg.kg-1 plus midazolam 0.05 mg.kg-1 (M + M) in 40 pediatric outpatients (age 1 to 17 years) undergoing upper endoscopy procedures. The physician and nurse performing the procedure were asked to rate cooperation, emotional status, drowsiness, and overall efficacy. A blinded observer recorded the frequency of negative behaviors indicating distress, vital signs, and oxygen saturation before, during, and after the procedure. No significant differences were noted in the overall efficacy of the regimens. Good or excellent efficacy was noted in 15 of 21 children (71%) in the M group and 15 of 19 children (79%) in the M + M group by physicians; nurses assigned a good or excellent rating for 14 of 21 (67%) and 13 of 19 (68%) in the M and M + M groups, respectively. Immediately following the procedure, amnesia was noted in 4 of 17 (23%) patients who received M versus 14 of 18 (78%) patients who received M + M (P = 0.002). Of the children who received M + M, the amnesia tended to occur more frequently in older children (> 11 years, 8 children, rate of amnesia 100%) than in younger children (< or = 11 years, 6 of 10 evaluable children, rate of amnesia 60%). There was no significant difference between the frequency of negative behaviors, rate of adverse effects, or changes in vital signs or oxygen saturation noted with the two drug regimens.(ABSTRACT TRUNCATED AT 250 WORDS)

Positive side effects in the treatment of SIB using the Self-Injurious Behavior Inhibiting System (SIBIS): implications for operant and biochemical explanations of SIB.

The rate of self-injurious head hitting was reduced using contingent electric shock delivered via the Self-Injurious Behavior Inhibiting System (SIBIS). Positive side effects indicating an improved affective state and increased interaction with the environment were documented. Treatment gains were maintained at a 1-year follow-up assessment. The consistent reports of positive affective side effects from successful treatment studies using SIBIS and contingent electric shock are noted. Implications for current operant-based theories of SIB based on the communication function of SIB and endogenous opiate mechanisms are discussed.

Efficacy of diazepam and meperidine in ambulatory pediatric patients undergoing endoscopy: a randomized, double-blind trial.

Medications are routinely administered to children prior to upper gastrointestinal endoscopy procedures. We evaluated the efficacy and safety of four dosage regimens: meperidine 2 mg/kg (M); low-dose meperidine 1 mg/kg and diazepam 0.1 mg/kg (M low+D); high-dose meperidine 2 mg/kg and diazepam 0.1 mg/kg (M high+D); and, diazepam 0.1 mg/kg (D) in a randomized, double-blind trial in 71 pediatric patients (ages 1 to 19 years). Cooperation, emotional state, and sedation were rated. The frequency of negative behavior demonstration (i.e., crying, gagging, flailing, nervous behavior) indicating ineffective or inadequate sedation was recorded before, during, and after the procedure. Vital signs and oxygen saturation were noted. Significant differences were observed in the efficacy of the various sedation regimens. Overall, the physicians and nurses rated M most effective in children < 11 years. In these children, M high + D and D were rated least effective by the nurses, whereas physicians felt that D was least effective. In the older children, M, M low + D, and M high + D were rated similarly effective by physicians and nurses, and D was rated least effective. In both age groups, the lowest incidence of negative behaviors during the endoscopy procedure occurred in patients who received M. Combinations of D and M + D resulted in an increased incidence of negative behaviors; thus, M may be the preferred sedation regimen in children undergoing endoscopy. The addition of diazepam to meperidine may be detrimental in terms of eliciting negative behaviors.

Going "all out" pharmacologically? A re-examination of Berkman and Meyer's "alternative strategies and multiple outcomes in remediation of severe self-injury: going 'all out' nonaversively".

Berkman and Meyer (1988) is frequently cited as evidence of the effectiveness of positive-oriented programming approaches and in opposition to aversive procedures. In that report, Berkman and Meyer attributed reductions in a client's self-injurious behavior to their intervention. They appeared to rule out the possibility that medication could have been responsible for behavior changes by reporting that medication was held constant during their intervention. We have recently obtained medication records indicating that (a) Berkman and Meyer incorrectly reported their client's medication status during their intervention and (b) there appears to have been a relation between the introduction of Thorazine (with subsequent increases in dosage) and reductions in the client's self-injurious behavior.

Psychosocial adjustment and physical growth in children with imperforate anus or abdominal wall defects.

Pediatric surgeons have the unique responsibility of performing surgical procedures that will enable their patients to function normally throughout a lifetime. Good anatomic results may not ensure that this goal will be achieved. Using a battery of psychological testing instruments, we evaluated the academic achievement and psychosocial status of 56 children (mean age, 10.6 years) with imperforate anus (IA) and abdominal wall defects (AWDs). Physical growth was assessed by measurement of standard anthropometric parameters, and a parent questionnaire was used to define clinical status. As a group, the children presented with average intellectual ability. Achievement in both reading and math was in the normal range. In 12.5% of the children a reading learning disability was noted and 10.7% had a disability in math. On the basis of parental assessments, 25% of the children demonstrated externalizing behavior disorders (eg, conduct problems) and 29% displayed internalizing symptomatology (eg. withdrawal, anxiety). Social competency deficits were described in 23% of the children. Data obtained from the teachers were consistent with the parental assessments. No major differences between the IA and AWD patients in academic achievement, psychosocial status, or physical growth were discovered. Routine screening of these children for learning disabilities and behavior problems is recommended.

Clinical evaluation of the self-injurious behavior inhibiting system (SIBIS).

Five cases involving the treatment of longstanding, severe, and previously unmanageable self-injurious behavior are presented. In each case, the behavior was forceful contact with the head or face, and treatment consisted of mild and brief contingent electrical stimulation, delivered automatically or by a therapist, via the Self-Injurious Behavior Inhibiting System. Results of reversal and/or multiple baseline designs, in which sessions ranged in duration from 10 min to all day across a variety of settings, showed that the effects of the system were immediate and produced almost complete elimination of the self-injurious behavior. Controlled and anecdotal follow-up data for four of the five cases suggest continuing benefits and the absence of detrimental side effects associated with treatment. Potential applications of the device, as well as extensions and limitations, are discussed.

Behavioral adjustment of pediatric burn victims.

Investigated the relationship of a variety of biopsychosocial variables to maternal ratings of children's psychosocial adjustment in a sample of 68 child burn survivors. Results indicated that (a) the mean maternal ratings of behavioral adjustment for pediatric burn patients did not differ from those reported for nonburned, nonclinic children, (b) a relatively small but statistically significant percentage of children had overall adjustment scores in the deviant range, and (c) little variance in the behavioral outcome measures was accounted for on the basis of three sets of predictor variables (demographic, burn severity, injury visibility) hypothesized to influence children's adjustment. Results suggest that the prevalence of behavioral disturbance in long-term pediatric burn survivors may be lower than previous reports have indicated. Implications of the results for consultation and future research are discussed.

Adjustment to diabetes mellitus in preschoolers and their mothers.

Although preschool-aged children with diabetes might be at increased risk for both general and disease-specific psychological adjustment difficulties, this issue has not been investigated. We evaluated both general and diabetes-related adjustment of 20 preschool-aged children and their mothers. The mothers completed the Child Behavior Checklist, Parenting Stress Index, Parents' Diabetes Opinion Survey, and the Preschool Diabetes Behavior Checklist. The latter measure was constructed specifically for this study to measure the frequency of oppositional and avoidance behaviors of children regarding diabetes management tasks. Mothers reported that their children displayed significantly more internalizing behavior problems (anxiety, depression, withdrawal) and were a significantly greater source of parental stress compared with corresponding nondiabetic normative group samples. Also, certain maternal attitudes about diabetes and its treatment were correlated with the children's disease-specific behavior problems. The children's general psychological adjustment, however, was not predictive of these diabetes-specific behavior problems.

Anxiety reduction in children receiving medical care: developmental considerations.

The present investigation examined the importance of considering age-related conceptual abilities when designing preparation interventions for hospitalization and medical procedures. Forty-eight children, ages 3-5 years and 7-10 years, viewed videotaped information about an upcoming medical procedure. The children were assigned to one of three treatment conditions: control, developmentally appropriate information, developmentally advanced information. Results suggest that information which is designed to match the age-related conceptual abilities of the recipient more effectively reduces anxiety and increases cooperation. Implications for future research evaluating efficacy of preparation strategies are noted.

Ecobehavioral characteristics of a pediatric burn injury unit.

Behavioral observations were conducted on 40 children admitted consecutively to an inpatient pediatric burn care unit (PBCU) over a 6-month period. Children's responses to the PBCU environment as well as adult responses to patients were assessed. Data indicated that children most frequently (a) were oriented and alert, (b) emitted vocalizations or verbalizations, (c) were environmentally engaged, (d) and demonstrated positive or neutral affective responding. Adult-child interactions occurred during the majority of observations. Age was found to be significantly related to the type of distress response exhibited. Positive responses indicative of patient well-being were found to be associated with environmental engagement and the presence of other patients. In general, little evidence emerged to support the notion of a PBCU response pattern which resembles that observed in pediatric intensive care units (i.e., ICU syndrome). The use of observational methods for studying the behavioral adaptation of children in medical settings and the implications of the data for the design of interventions on PBCUs are discussed.

Use of time-lapse video recording for the direct measurement of behavior in the mentally retarded.

In the present paper behaviors of mentally retarded children were recorded simultaneously on real time and time lapse video recorders. Behaviors on the time lapse recordings occurred at a rate 12 times faster than they actually occurred in real time resulting in a 92 percent reduction in the time required to score the tapes. Reliability estimates from real time and time lapse records were high and correspondence between the two methods was good. The limitations of time lapse and the feasibilities for the extended use of time lapse video recorders in behavioral and ecobehavioral assessment of mentally retarded individuals are discussed.

Toward a methodology of the short-term effects of neurodevelopmental treatment.

Neurodevelopmental treatment (NDT) is a technique widely used by physical and occupational therapists in the treatment of neuromuscular disorders; however, quantitative evidence supporting its use has yet to be provided. Several studies have attempted to examine the effects of NDT, but because of poor research methodology, conclusions drawn to support the use of NDT are not based on reliable or well-documented evidence. The purpose of this study was to develop a reliable method of measuring short-term, objective changes in children with cerebral palsy and to measure the immediate effects of NDT and play interventions. A single subject design was replicated with four subjects receiving NDT and nonspecific play over a 5-week time period. Pre- and post-test items were designed to reflect qualitative changes in movement, postural tone, and reflex activity, and were videotaped and coded using interval and time-sampling techniques. The results of this study are equivocal; they neither validate nor invalidate NDT. This study provides a methodology for the investigation of the short-term effects of NDT.

The obese child.

Forty-five percent of adult obesity cases begin in infancy. Obese children can be identified early; eating and activity patterns are characteristic. It is not known whether obesity is genetically or environmentally determined, but it clearly runs in families; the child of obese parents is at risk. After endogenous obesity has been ruled out, management requires caloric restriction, increased physical activity, and careful record keeping.

Single-subject design and interaction analysis in the behavioral treatment of a child with a feeding problem.

A research paradigm, including an AB1AB2 single-subject design was developed and used in conjunction with an adult-child interaction analysis methodology to evaluate the effectiveness of a behavioral treatment approach to a feeding problem in a 2 1/2-year-old male. The results indicate that after nine treatment sessions, the child's diet was appropriate and the undesirable mother-child interaction pattern was changed. In addition, the interaction analysis methodology was used to evaluate the therapist's behavior modification techniques so that these could be taught to the mother. This study continued the previous endeavors to delineate feeding problems in children and subsequently to treat these problems with a behavioral approach. This kind of systematic research, with functional analysis of presenting problems and specification of the therapist's treatment behavior, is offered as a clinically appropriate paradigm for psychotherapy and behavior modification research.