Comparative analysis of self-injurious behaviour topographies in young children with and without developmental delay.

BACKGROUND: The present study presents post hoc analyses of specific topographies of self-injurious behaviour (SIB) exhibited by young children with developmental delay (DD) and children with typical development (TD). We conducted these analyses to better understand similarities and differences between the groups from a developmental perspective. No previous study has compared the prevalence, severity and co-occurrence of specific topographies of SIB in young children. METHOD: The participants were parents of two groups of children one with DD (n = 49, mean age = 37.5 months) and one with TD (n = 49, mean age = 36.6 months). Individual items of the SIB subscale from the Repetitive Behaviour Scale-Revised were used in the analyses. RESULTS: Seven of the eight Repetitive Behaviour Scale-Revised SIB categories were reported for both groups. Children in the DD group were significantly more likely to engage in Hits Self against Surface or Object, Hits Self with Body Part, Inserts Finger or Object, Skin Picking and Bites Self. Parental ratings of severity were also significantly greater for the DD group for these five topographies. The DD group engaged in a significantly greater number of SIB topographies than the children in the TD group. Children in the TD group were more likely to exhibit a single SIB topography while the DD group were more likely to engage in two or more topographies. Topographies involving self-hitting were not only more frequent among the children in the DD group but also more likely to be rated as moderate or severe in nature. CONCLUSIONS: Compared with the TD group, the topographies of SIB exhibited by the DD group were more prevalent, more severe and co-occurred with greater frequency. Inclusion of a group of children with TD provided an important comparative context for the occurrence of SIB in children with DD.

Trazodone is only slightly faster than fluoxetine in relieving insomnia in adolescents with depressive disorders.

This retrospective chart review examined the relative effectiveness of fluoxetine and trazodone in relieving insomnia associated with depressive disorders in adolescents (aged 13-17 years). We reviewed the hospital charts of consecutively admitted adolescents with a depressive disorder and insomnia, who received one of three treatments: fluoxetine (20 +/- 2.2 mg), trazodone (71 +/- 32 mg), or a fluoxetine-trazodone combination (fluoxetine 29 +/- 2.2 mg, trazodone 68 +/- 29 mg). Each treatment was examined in 20 patients. Insomnia was defined as a change in sleep patterns characterized by decreased total sleep time that was sufficient to cause clinical concern, and insomnia resolution was defined as sleep starting by midnight and lasting 6 hours. Mean time to resolution of insomnia was significantly faster in adolescents treated with trazodone rather than fluoxetine (2.5 vs. 5.1 days, p < 0.05). Trazodone seemed to save only about 3 days and insomnia resolved in all subjects by the 11th day of antidepressant treatment. Median time to insomnia resolution was 2 days (range 1-5 days) in the trazodone group and 4 days (range 1-11 days) in the fluoxetine group. This difference between trazodone and fluoxetine, although statistically significant, was generally not clinically significant in the management of insomnia associated with depressive disorders in adolescents. The resolution of insomnia was not faster for treatment with a combination of fluoxetine and trazodone in comparison to fluoxetine monotherapy. Insomnia resolution was slightly later in older children. These clinical findings await confirmation by a controlled study. Both drugs seemed effective in ameliorating sleep symptoms in this sample, although it is likely that they produced these changes by different mechanisms.

The child with attention deficit hyperactivity disorder and learning disability.

The following case is presented to demonstrate the difficulties associated with treatment of Attention Deficit Hyperactivity Disorder (ADHD) when it is comorbid with a learning disability (LD). These two disorders exist simultaneously in about 30% of those diagnosed with ADHD. It is often difficult to separate the effects of one condition from those of the other. Researchers and clinicians often struggle with questions concerning the origin of inattentive symptoms. A child with LD may have trouble attending if placed in a classroom setting not designed to deal with issues related to LD, while a child with attention deficit may not be progressing as well as expected because of problems maintaining attention. This case highlights the need for a multi-faceted approach to the treatment of ADHD, as well as, the need for continued evaluation of the effectiveness of the treatment plan instituted.

The Objective Structured Clinical Examination (OSCE) in the clinical clerkship: an overview.

The Objective Structured Clinical Examination (OSCE) for student assessment is well established, with an extensive body of research documenting that this is a valid means to assess clinical skills that are fundamental to the practice of medicine. The OSCE consists of a circuit of stations which tests a range of skills and learning to assess undergraduate medical students. A well-constructed OSCE provides important information about candidate performance and the quality of training. It is used at the University of South Dakota School of Medicine (USDSM) in assessment of third year medical students during their Obstetrics Clerkship, and as a teaching tool in the Pediatric Clerkship. On August 10, 1996, the USDSM administered an OSCE for the first time to third year medical students. The purpose of this article is to present state of the art information about setting up OSCE based on our recent experience and to provide practical examples of OSCE questions which can be addressed in the clinical setting. The narrative, references and examples give guidelines for the preparation of OSCE testing. The OSCE provided a standardized way of assessing clinical competence. Both students and faculty were very satisfied with the examination, and felt that the material tested was relevant and appropriate. The OSCE process does serve to identify areas of weakness in the curriculum and/or teaching methods, and thus can serve as a mechanism to improve educational effectiveness.

Heterogeneity of nemaline myopathy. A follow-up study of 13 cases.

The marked heterogeneity of nemaline myopathy is again shown in the present series of 13 patients. Most children have a long-standing, mild, and slowly progressing proximal myopathy. Two brothers with extreme weakness died during the neonatal period of respiratory failure representing the X-linked variant. One adult with proximal weakness was also diagnosed as having nemaline myopathy. An unusual course was observed in 2 infants who initially had moderate weakness but subsequently developed severe generalized weakness including respiratory muscles. This led to irreversible respiratory failure requiring continuous ventilatory support for as long as 9 and 15 years, respectively. Although uncommon, the possibility of an imminent respiratory failure in initially weak infants should also be taken into account within the clinical spectrum of nemaline myopathy.

Rehabilitation of communication impairment in dystonia musculorum deformans.

Augmentative and alternative communication (AAC) aids were used in three young, intellectually normal patients with dystonia musculorum deformans (DMD) who had severe speech and writing impediments. These aids included speech therapy, communication boards, and voice synthesizers for verbal communication and typewriters, memowriters, and computer software and printers for written communication. At times customized accessing was needed which required specific adaptive modifications. Implementation of the AAC aids system was determined effective for DMD patients in view of the intellect-sparing nature of the disorder. Improvement was hampered by the progressive nature of the disease and by the emotional stress of accepting the long-term use of AAC. Correct and early diagnosis of communication impediments are crucial for the appropriate AAC aids prescription and implementation. An AAC protocol is suggested to meet the special communication needs of DMD patients.

Vaccinations and the physically handicapped child.

The vaccination status of 98 physically handicapped children was examined to identify factors associated with an inadequate vaccination status. Of the 98 children, 57 had cerebral palsy, 14 had myelomeningocele, 3 had muscular dystrophy and 24 had myelomeningocele, 3 had muscular dystrophy and 24 had other motor disabilities. According to the available vaccination records, only 17 children had received all the recommended injections on schedule; 26 had missed at least one injection, and 3 of them had never been vaccinated. The overall rate of vaccination in our study group (63%) was lower than expected. The children with moderate to severe limitation of function due to cerebral palsy were significantly less likely (P less than 0.05) than those with less severe limitations to have received a basic series of vaccinations. Health departments must ensure that physically handicapped children receive the preventive health measures viewed normal and appropriate for other children.

Wheelchair users at a children's rehabilitation center: attributes and management.

A survey was made of the clinical characteristics of wheelchair-users at the Children's Rehabilitation Centre in Saskatoon, Saskatchewan. 261 patients were studied, of whom 214 had cerebral palsy, 34 had myelomeningocele and 13 had Duchenne muscular dystrophy. Among the patients with cerebral palsy it was found that the attributes likely to define a wheelchair-user were spastic quadriplegia, functional level III and IV, seizures and severe sensory handicap; among patients with myelomeningocele, wheelchair use ws related to level of lesion; and in the muscular dystrophy group it ws related to age. These results have been of help to rehabilitation centres and related service agencies in formulating long-term plans to meet the needs of wheelchair-users.

Management of cleft lip and palate: a team approach.

Cleft lip and/or palate is a common congenital malformation. The initial management of the affected infant and family begins in the delivery suite in the hands of the family physician. With patient, informed psychosocial counselling, the family should be told the origin of the malformation, practical tips on managing their child, especially feeding and attending to middle ear infections, and the work of the cleft lip and palate team. The family physician is a vital member of this team, as he is able to advocate for the best interests of the child and family.

The child with delayed language: assessment and management.

Speech and language disorders are the most common developmental problems among preschool children. Early detection and remediation of delayed language development are important in helping the child establish appropriate social behavior and acquire additional information about the world through the use of language.The major reasons for delayed language acquisition are mixed developmental delay, hearing loss, psychosocial factors, behavioral disturbance, specific language disorder, and major physical handicap. Assessment and management are outlined here by case presentations and discussions. The family physician can play a key role as part of a team of professionals concerned with language delay. (Can Fam Physician 1981; 27:1405-1412).

Developmental screening, well baby care in Saskatchewan family practice.

A total of 246 Saskatchewan primary care physicians were contacted to identify those in family practice and doing well baby care; 65 urban and 44 rural physicians were surveyed.The urban physicians had similar practice patterns, attitudes and approaches to developmental surveillance, except that Regina physicians saw more patients daily (p<0.005) and 25/29 routinely referred suspected children versus eight of 36 in Saskatoon.All physicians, rural and urban, relied on their "clinical impressions" to detect a developmentally delayed child. No one regularly used a formal developmental screening test. They cited time, cost and questionable value as major barriers. No one identified a regional child's rehabilitation centre as an assessment or management resource.Family physicians, regardless of practice location, should tailor their practices to insure early detection and appropriate referral of the developmentally delayed child, thereby minimizing disability and maximizing the child's potential.

Sicca syndrome and total lipodystrophy: a case in a fifteen-year-old female patient.

A 15-year-old girl is described with the sicca syndrome of keratoconjunctivitis and xerostomia. There was no associated rheumatoid arthritis or other connective tissue disorder, but total lipodystrophy had been present since the age of 9 years. Marked hyperreactivity of the humoral immune system and suppression of cell-mediated immunity was shown. The association of sicca syndrome with total lipodystrophy has not previously been reported.