Depression in Childhood and Early Adolescence: Parental Expressed Emotion and Family Functioning.

Across development depression is associated with impairments in interpersonal and family functioning. In turn, these impairments may predict a more negative depression course and outcome. This study examined family functioning and parental Expressed Emotion (EE) among depressed youth during middle childhood and early adolescence and their relationship to demographic and clinical factors. Data were drawn from pretreatment evaluations of 132 depressed youth ages 7-14 and their families enrolled in a randomized clinical trial comparing family to individual treatment for youth depressive disorders. Families completed semi-structured diagnostic interviews, self-report measures of family functioning, and the Five Minute Speech Sample EE measure. High parental EE was more common in one-parent, as opposed to two-parent families, and early adolescent youth were more likely than pre-adolescent youth to have high critical EE parents. Severity and chronicity of child depression, child comorbidity, functional impairment, and maternal depressive symptoms were not associated with parental EE. Parental high EE overall and critical EE in particular were associated with reports of higher conflict and lower cohesion by both parents and children when compared to low parental EE. Similar patterns of associations were evident for youth across pre-adolescent and early adolescent developmental periods. Single parent status may be an indicator of greater family stress; and higher levels of critical EE may reflect the higher levels of parent-child conflict characteristic of the transition from late childhood to early adolescence. Among youth with depression parental EE appears to reflect potentially important impairments in family functioning.

[Knee gouty monoarthritis. An arthroscopic view]. / Monoartritis gotosa de rodilla "una vista artroscópica". Reporte de un caso clínico.

INTRODUCTION: Gout is the symptom caused by the response to monosodium urate crystals that develop due to hyperuricemia; it is the most frequent inflammatory arthropathy in males over age 40. OBJECTIVE: To demonstrate the diagnosis as an arthroscopic finding. MATERIAL AND METHODS: The case of a male, 39 year-old patient without a relevant medical history whose illness started with left knee trauma consisting of rotation and forced valgus. He initially had pain and inflammation and was treated with immobilization for two weeks. Pain and inflammation persisted so plain films and MRI were ordered and they showed a lesion of the medial meniscus. Arthroscopy of the left knee was performed. RESULTS: The nuclear MRI showed a lesion of the medial meniscus and a chondral lesion of the medial condyle. Preoperative tests showed a uric acid level within the upper normal limit. The arthroscopy showed a transverse lesion of the medial meniscus that was repaired as usual; lesions were found throughout the articular surface, with crystal deposits, as well as an important synovial inflammatory reaction and medial condyle chrondropathy. DISCUSSION: Arthroscopy of a gouty knee shows urate deposits that partially cover the synovial, the anterior cruciate ligament, the menisci and lesion zones in the articular surfaces. Removal of gouty collections and a thorough articular lavage improve the local symptoms of the disease. No synovectomy was performed, as is recommended in the literature.

[Management of congenital adduct clubfoot with the Ponseti technique. Experience at "La Perla" General Hospital]. / Manejo del pie equinovaro aducto congénito con técnica de Ponseti. Experiencia en el Hospital General "La Perla".

UNLABELLED: The purpose of this paper is to present the experience of the hospital using the Ponseti method in patients with congenital adduct clubfoot. MATERIAL AND METHODS: The study was conducted between January 2007 and December 2009. Children of both sexes were included; the Dimeglio classification was applied before surgery and their course was later assessed with the Simons scale when they resumed gait. Patients with postural clubfoot (Dimeglio I) and those with neuromuscular disease (Dimeglio IV) were excluded. Casts were placed as of 15 days of age using the Ponseti technique and then percutaneous tenotomy of the calcaneous tendon was performed in the operating room. RESULTS: Twenty patients (9 girls, 11 boys) and 28 feet were included in the study; they were Dimeglio II (8 children) and III (12 children). Mean age at the time of surgery was 2 months, and mean age at the time of gait assessment was 2 years. Upon applying the Simons scale, 25 feet (89.3%) had satisfactory results and 3 feet (10.7%) unsatisfactory results. Two of the latter underwent percutaneous tenotomy again and in one case the cast was applied again; they evolved properly. CONCLUSIONS: We found in our series that the Ponseti technique is appropriate as definitive treatment for Dimeglio II and III congenital adduct clubfoot.

Luxación inveterada de codo en niños / Old unreduced elbow dislocation in children

Se realizó un trabajo de investigación sobre el resultado del tratamiento quirúrgico de la luxación inveterada de codo en niños. Entre 1985 y 2000 fueron tratados 22 niños con dicho diagnóstico. La edad media en el momento de la lesión fue de 11,9 años y el tiempo medio entre la lesión y la intervención quirúrgica de 1,4 años. Diecinueve pacientes fueron tratados con reducción abierta y fijación con clavo intraarticular. Entre dos y tres semanas se les retiró el clavo e iniciaron fisioterapia activa; el tiempo medio de seguimiento fue de 2,7 años. Cuarenta y cinco por ciento de los pacientes tuvieron excelentes resultados ya que recuperaron al 100 por ciento los arcos de movilidad, 32 por ciento aumentaron los arcos de movilidad, 14 por ciento no tuvieron mejoría y 9 por ciento no recuperaron los movimientos o tuvieron alguna complicación. Se estudiaron los siguientes puntos: la evolución de acuerdo con las semanas que los pacientes estuvieron con el clavo, la relación entre edad y resultado postquirúrgico, y la relación entre el tiempo transcurrido de la lesión y la recuperación de los arcos de movimientos. Observamos que los pacientes tenían mejor evolución cuando se les retiró el clavo a las tres semanas. No hubo relación entre la edad y la evolución postquirúrgica; el tiempo transcurrido entre la lesión y el tratamiento quirúrgico no fue factor determinante para la recuperación de los arcos de movimiento. (AU)

Depression in youth: psychosocial interventions.

Witnessed over the past 20 years are major advances in knowledge regarding depression in children and adolescents. Although additional research is needed, clinicians can now turn to treatment strategies with demonstrated efficacy. In this article we review the literature on psychosocial interventions for depression in youth and offer a working model to guide the treatment of depressed youth. We begin with a brief overview of the model, followed by a review of the treatment efficacy and prevention literatures. We offer some caveats that impact the ability to move from this treatment literature to the real world of clinical practice. We conclude by considering how extant research can inform treatment decisions and highlight critical questions that need to be addressed through future research.

Is expressed emotion a specific risk factor for depression or a nonspecific correlate of psychopathology?

Five Minute Speech Sample Expressed Emotion (FMSS-EE) was examined in families of youth with depressive disorders, nondepressed youth with attention deficit/hyperactivity disorder (ADHD), and community controls screened for the absence of depression and ADHD. Consistent with the hypothesis that FMSS-EE shows some specificity as a risk factor for depression, rates of critical EE were significantly higher among mothers of youth with depression as compared to mothers of nondepressed youth with ADHD, or mothers of controls. When both mothers' and fathers' scores were used to generate family EE ratings, rates of overall EE and critical EE were significantly higher for the depressed group than the control group, but the nondepressed ADHD group did not differ significantly from the other groups. Results support the hypothesis that critical EE in mothers shows some specificity as a risk factor or correlate of depression in youth.

Difficulty in implementing a family intervention for bipolar disorder: the predictive role of patient and family attributes.

Family affect was examined as a predictor of difficulty implementing a 9-month, manual-based, psychoeducational family therapy for recently manic bipolar patients. Prior to therapy, family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task. Following family treatment, both therapists and independent observers rated the overall difficulty of treating the family, and therapists also rated each participant's problem behaviors during treatment, in the areas of affect, communication, and resistance. Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family. Relatives' critical behavior toward patients during the pretreatment interaction task predicted both independent observers' ratings of overall treatment difficulty and therapists' perceptions of relatives' affective problems during treatment. Moreover, patients' residual symptoms predicted independent observers' ratings of overall difficulty and therapists' perceptions of patients' resistance to the family intervention. Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic, pretreatment family and clinical assessment.

Childhood-onset schizophrenia: a follow-up study.

This paper presents results from the UCLA Follow-Up Study of Childhood-Onset Schizophrenia Spectrum Disorders. Eighteen children with schizophrenia (SZ) were assessed 1 to 7 years following initial project intake. Results demonstrated significant continuity between SZ spectrum disorders in childhood and adolescence. Although not all children who presented initially with SZ continued to meet criteria for SZ spectrum disorder as they progressed through the follow-up period, rates of SZ spectrum disorders ranged from 78-89% across the first three follow-up years. Rates of continuing SZ ranged from 67% to 78% across the three follow-up years and rates of schizoaffective disorder ranged from 11% to 13% across the three follow-up years. Variability in levels of functioning were observed with 45% of the sample showing deteriorating course or minimal improvement and 55% of the sample showing moderate improvement or good outcomes. This variability in outcome is comparable to that seen in adults with SZ, suggesting that with current treatments childhood-onset does not ensure a more severe disorder.

Family interaction styles of children with depressive disorders, schizophrenia-spectrum disorders, and normal controls.

Family interaction processes during a problem-solving task were examined in children with depressive disorders, children with schizophrenia-spectrum disorders, and a normal control group of community children screened for the absence of psychiatric disorder. Major findings were: a) children with depressive disorders were more likely than children with schizophrenia-spectrum disorders and children with no psychiatric disorder to direct guilt-inducing comments toward their parents; and b) parents of children with schizophrenia-spectrum disorders were more likely to direct harsh critical comments toward the child than were parents of depressed children or parents of normal controls. In addition, children's and mothers' use of benign criticism was linked, while children's harsh criticism was associated with intrusion from the father, and children's self-denigrating comments were related to specific paternal criticism. Implications of these results for understanding transactional processes associated with childhood-onset depressive and schizophrenia-spectrum disorders are discussed.

Evaluating therapist competency and adherence to behavioral family management with bipolar patients.

The present study assessed fidelity to the behavioral family management (BFM) model for treating bipolar disorder patients and their families. The BFM Therapist Competency/Adherence Scale (BFM-TCAS) was developed to evaluate clinicians' competency and adherence to BFM, as outlined by Miklowitz' (1989) BFM Manual for use with bipolar patients. Therapist competency and treatment adherence was also evaluated with regard to two family characteristics: overall level of family difficulty and family expressed emotion (EE) status. The BFM-TCAS was used to code 78 videotaped sessions of 26 families with a bipolar member, selected from a larger treatment study of bipolar disorder patients. The findings suggest that, overall, clinicians adhered closely to the BFM manual. Specific areas in which there was high competency and treatment adherence were (a) skill in conveying factual information about bipolar illness, (b) establishment of a therapeutic environment, and (c) ability to take command of therapy sessions. The one area in which there was less competency and relatively weak adherence to the manual was the use of between-session homework assignments to assist families in mastering the BFM exercises. Results of this study also suggest that, for the most part, therapist competency and adherence ratings were not related to overall level of difficulty or to family EE status.

Children with schizophrenia-spectrum disorders: thought disorder and communication problems in a family interactional context.

Thought disorder and communication patterns during an interactional task were examined in families of children with schizophrenia-spectrum disorders (schizophrenia and schizotypal personality disorder), depressed children, and normal controls. Children with schizophrenia-spectrum disorders showed significantly more thought disorder than their normal peers; levels of thought disorder among depressed children fell between those observed in the other two groups but did not differ significantly from either of them. Similarly, mothers of children with schizophrenia-spectrum disorders showed more thought disorder than mothers of normal control children but did not differ from mothers of depressed children. Children with schizotypal personality disorder did not differ from children with schizophrenia. These findings demonstrate that the thought disorder present in childhood-onset schizophrenia and schizotypal personality disorders is manifest in an important social context, the family.

Schizophrenic patients' perceptions of their relatives' attitudes.

Although the attitudes of family members as revealed by measures of expressed emotion (EE) have been shown to be associated with the course of schizophrenic illness, little is known about how the patients perceive these attitudes. A detailed interview was used to assess patients' perceptions of their family members' behaviors toward them. Family member's EE was assessed with the Five-Minute Speech Sample (FMSS). Overall, patients' perceptions of criticism were congruent with a component of the FMSS-EE that measures criticism. Results indicated that when family members had high EE/critical scores, patients perceived them as displaying more instances of critical behavior. All cases in which patients' perceptions of criticism were incongruent with measures of FMSS-EE occurred among ethnic minority group members. Although the FMSS-EE did not predict outcome in this study, patients who perceived their relatives as higher in criticism had more negative outcomes at 1 year. These findings suggest that when family environments are examined in patients from ethnic minority groups, the patients' perspective may be a more potent predictor of outcome than traditional measures of EE.

Family-expressed emotion, childhood-onset depression, and childhood-onset schizophrenia spectrum disorders: is expressed emotion a nonspecific correlate of child psychopathology or a specific risk factor for depression?

Expressed emotion (EE) was examined, using the brief Five Minute Speech Sample measure, in families of (1) children with depressive disorders, (2) children with schizophrenia spectrum disorders, and (3) normal controls screened for the absence of psychiatric disorder. Consistent with the hypothesis of some specificity in the association between EE and the form of child disorder, rates of EE were significantly higher among families of depressed children compared to families of normal controls and families of children with schizophrenia spectrum disorders. Within the depressed group, the presence of a comorbid disruptive behavior disorder was associated with high levels of critical EE, underscoring the need to attend to comorbid patterns and subtypes of EE in future research.

Childhood-onset schizophrenia: a followup study.

This article is an overview of our studies of childhood-onset schizophrenia. Data are presented demonstrating that (1) the majority of the sample showed continuing schizophrenia as they progressed through adolescence; (2) there was considerable variability in outcome, defined by global adjustment scores, with 56 percent of the sample showing improvement in functioning during a 2- to 7-year followup period and the other 44 percent showing minimal improvement or a deteriorating course; (3) schizophrenia in childhood could be diagnosed by the same criteria used for adults and was associated with severe dysfunction; and (4) some intrafamilial attributes found to be associated with schizophrenia in adults were also associated with schizophrenia in children, but there were some differences in the family environmental correlates of childhood- and later-onset schizophrenia. These data are consistent with the hypothesis that childhood- and later-onset schizophrenia represent the same illness or illnesses. Additional research is needed, however, to clarify the etiologic and clinical significance of the atypical early onset in childhood cases.

Patients' perceptions of family emotional climate and outcome in schizophrenia.

Thirty-nine chronic schizophrenic male out-patients and their relatives were interviewed separately to assess their perceptions of their current relationships. Two simple 5-point rating scales predicted the risk of psychotic exacerbation during a one-year follow-up: patients' perceptions of the relatives' attitudes towards them, and patients' own attitudes towards the relatives. Survival analysis of data in a 2 x 2 factorial--combining degree of contact with the key relatives and the patients' perceptions of their relatives--found that patients in frequent contact with a positively perceived relative had significantly better survival rates without psychotic exacerbation. Patients' perceptions of their relatives may help identify patients at risk of exacerbation of their illness.

One-year outcomes of depressive disorders in child psychiatric in-patients: evaluation of the prognostic power of a brief measure of expressed emotion.

The association between 1-year post-hospitalization outcome and the brief Five Minute Speech Sample (FMSS) measure of expressed emotion (EE) was examined among children with depressive disorders. Results indicated a strong association between 1-year outcome and the FMSS-EE measure. Whereas children returning to high EE homes were likely to show persistent mood disorder, recovery was more common among children returning to low EE homes. This predictive relationship was independent of possible mediating variables such as treatment regimen and clinical characteristics. Results provide the first reported demonstration that (1) the brief FMSS-EE measure predicts clinical outcome, and (2) EE measures predict 1-year outcome for children with depressive disorders.

Factors affecting a clinician's decision to provide fieldwork education to students.

Fieldwork represents an important component of the education of an occupational therapist. In this study thirteen occupational therapists in small Saskatchewan occupational therapy facilities were interviewed to determine the factors and the relationships among these factors that affected their involvement in the fieldwork process. The directors of the two large occupational therapy departments in Saskatchewan, together with eight Canadian university fieldwork coordinators were interviewed for comparison purposes. The findings of the study have shown that there were four major influences affecting Saskatchewan therapists' involvement in the fieldwork program of occupational therapy students. They were: workload; feelings of isolation; the parameters of a placement; and professionalism. This study is important because it has identified significant factors for university fieldwork coordinators to consider in their contact with therapists. It has also provided a model for other similar studies.