Sport and recreation activities and opportunities for children with spina bifida and cystic fibrosis.

A survey, completed by 69 parents whose children have cystic fibrosis and 97 parents of children with spina bifida, showed that opportunities for participation in sport and recreation activities were significantly greater for children with cystic fibrosis than for children with spina bifida. Parents from both groups felt that there was not enough variety available, that there was difficulty finding suitable activities which involved the whole family and that they had found barriers to their child participating in sport and recreation activities. The stresses of having a child with a significant disability and trying to balance the needs of these children with those of other non-affected family members was reflected by the finding that both groups of parents had double the rate of psychological health problems that would be expected in the population.

Suicide risk following child sexual abuse.

OBJECTIVE: To determine the suicide rate and prevalence of suicide attempts and suicidal ideation in 183 young people who had experienced child sexual abuse and to examine variables related to the abuse, which may correlate with suicide attempts or suicidal ideation. METHODS: Adolescents and young adults who had experienced child sexual abuse and individuals from a nonabused comparison group were asked about suicide attempts and suicidal ideation 5 and 9 years after intake to the study. Nine years after the abuse, a national death search was carried out to ascertain the number and causes of death in the 2 groups. Logistic regression was used to assess information on demographic and family functioning variables, the sexual abuse, notifications for other child abuse, criminal convictions, and out-of-home placements that were related to the outcome variables. RESULTS: Young people who had experienced child sexual abuse had a suicide rate that was 10.7 to 13.0 times the national Australian rates. There were no suicides in the control group. Thirty-two percent of the abused children had attempted suicide, and 43% had thought about suicide since they were sexually abused. CONCLUSIONS: Little information seems to be available to clinicians at the time of investigations for child sexual abuse in children that may identify those who are at increased risk of suicide. Abuse by an acquaintance, parental denial, or being angry with the child and not the abuser may predispose to suicide attempts but not necessarily to a completed suicide.

Erroneous concerns about child sexual abuse.

AIM: To assess the incidence and nature of concerns about sexual abuse, with particular reference to erroneous concerns of sexual abuse made by children. METHODS: A review of case notes of all child sexual abuse reports to the Denver Department of Social Services over 12 months. Cases were put into four groups: substantiated, not sexual abuse, inconclusive and erroneous accounts by children. RESULTS: 551 cases were reviewed. Forty-three percent were substantiated, 21% were inconclusive and 34% were not considered to be abuse cases. There were 14 (2.5%) erroneous concerns emanating from children. They comprised three cases of allegations made in collusion with a parent, three cases where an innocent event was misinterpreted as sexual abuse and eight cases (1.5%) of false allegations of sexual abuse. CONCLUSION: Erroneous concern of sexual abuse from children are uncommon. The four categories of concern in this study, in contrast to the simple classification of substantiated and unsubstantiated, provide a means of encouraging open minded assessments of the typical concerns which a child protection agency receives.

Hoping and coping in young people who have been sexually abused.

BACKGROUND: Very little research has been conducted on the relationship between sexual abuse, reduced hopefulness and impaired coping. METHOD: The sample consisted of 22 abused young people (2 males (9%) and 20 females (91%)) and 29 nonabused young people (4 males (14%) and 25 females (86%)). Hopefulness, despair, depression, self-esteem, anxiety, number of negative life events and various parent, family and demographic variables were measured. The aim was to establish significant predictors of outcome, with outcome measured at the extreme end of the spectrum by self-injury and suicidal ideation and attempts. RESULTS: Depression predicted hopefulness and despair. Depression, anxiety, number of caregiver changes, despair and global personal hopefulness were significant predictors of outcome. Child sexual abuse itself was not a significant predictor of self-injury, suicidal ideation or suicide attempts in this sample. CONCLUSIONS: Each of the significant predictors of outcome, other than caregiver changes, has been linked to the learned helplessness paradigm. Depression and anxiety may be mediated by despair and hopefulness in their prediction of self-injury and suicidal attempts and ideation. To modify young people's long-term view of their futures and thereby reduce their vulnerability to depression and anxiety and in turn their tendency toward self-injury and suicide, something more than generic casework will be necessary. If self-injury, suicidal ideation and behaviour are to be effectively addressed, it is likely that anxiety and depression will need to be treated vigorously and attention will need to be paid to the perceived future.

Evaluation of a national surveillance unit.

AIM: The Australian Paediatric Surveillance Unit (APSU) facilitates national active surveillance of uncommon childhood conditions. This study assessed whether it fulfilled its objectives and satisfied criteria established by the Centers for Disease Control and Prevention (CDC) for evaluating surveillance systems. METHODS: Anonymous questionnaires were sent to users of the system, individual studies were reviewed, and data were collected from independent sources. RESULTS: Seven hundred and sixty six clinicians, 48 investigators, and 15 public health professionals responded to the questionnaires. Clinicians reported that the APSU was useful, 33% saying information provided by the APSU informed or changed their clinical practice. Most (88%) reported that completing monthly report cards was not a burden. Impact on policy development was limited by suboptimal dissemination of information to public health professionals. Flexibility and timeliness were limited by design. Estimated sensitivity of APSU studies ranged from 92% (congenital rubella) to 31% (drowning/near drowning). Positive predictive value of notified cases was over 70% for most studies. CONCLUSION: The APSU fulfils most of its objectives and meets CDC criteria salient to these. Ways in which the APSU could be improved have been identified, as have methodological challenges and limitations in applying CDC guidelines to this type of unit.

Subdural hematomas in children under 2 years. Accidental or inflicted? A 10-year experience.

OBJECTIVE: The aim of this study was to determine the relative frequency of child abuse, accidents and disease as a cause of subdural hematomas in children under 2 years of age, and to determine the main clinical features at presentation, that may help to distinguish these groups of patients. METHOD: A retrospective review was undertaken of the medical records of all children under 2 years of age admitted to the Royal Alexandra Hospital for Children with the diagnosis of subdural hematoma in the 10-year period January 1987 to December 1996. RESULTS: Thirty eight children were identified with subdural hematomas during the study period. The commonest cause was nonaccidental injury in 55% of cases, accidents in 39% and nontraumatic causes (6%) made up the remainder. The nonaccidental injury cases were significantly younger than the accidentally injured children. The most important clinical features were the significantly higher incidence of retinal hemorrhages and associated long bone and rib fractures in the abuse group. Delay in presentation for medical evaluation was also more commonly seen in the abused children. CONCLUSION: Nonaccidental injury is the commonest cause of subdural hematomas in children under 2 years of age. The presence of retinal hemorrhages, bone and rib fractures, delay in presentation and the young age of the infants, suggests child abuse is the most likely cause of these injuries.

Prior childhood sexual abuse in mothers of sexually abused children.

OBJECTIVE: To see if mothers who were sexually abused in their own childhood are at increased risk of their children being sexually abused and to see if prior sexual abuse in mothers affects their parenting abilities. METHOD: Sixty-seven mothers whose children had been sexually abused by others and 65 control mothers were asked about sexual abuse in their own childhood. The sexually abused children of mothers who had been sexually abused in their own childhood were compared with the sexually abused children of mothers who had not suffered child sexual abuse as children. Comparisons were made on self-esteem, depression and behavior in the children. RESULTS: Thirty-four percent of mothers of sexually abused children gave a history of sexual abuse in their own childhoods, compared with 12% of control mothers. Assessment of the sexually abused children for self-esteem, depression and behavior at the time of diagnosis, after 18 months and after 5 years showed no difference in any of these measures at any of the three time intervals between those whose mothers had suffered child sexual abuse and those whose mothers had not been abused. CONCLUSION: In this study, sexual abuse in a mother's own childhood was related to an increased risk of sexual abuse occurring in the next generation, although prior maternal sexual abuse did not effect outcome in children who were sexually abused.

Non-accidental burns in children.

A retrospective review of five hundred and seven consecutive admissions to a state-wide paediatric burns unit over a three year period was made to assess the characteristics of the burn injuries and to see which, if any, characteristics would help to distinguish accidental burns from burns which were due to abuse or neglect. In 86% of admissions (the 'accident group') it was considered that the injury was accidental, with no evidence of deliberate injury or gross neglect. Eight percent of admissions (the 'abuse/neglect group') were referred to the State Department of Community Services for abuse or neglect resulting in the Department becoming involved in the family's management. In six percent of cases (the 'concern group') the Unit had concerns that the family's emotional or social situation was a significant factor in the child's injury, or made further injury more likely, and discussed the family's situation with the Department, but formal intervention was not undertaken by the Department. There were no differences between the groups in age or mortality. Children in the 'abuse/neglect' and the 'concern' groups were more likely to require skin grafting and treatment in the intensive care unit. They were more likely to come from single parent families and were more likely to have burns involving both hands or both legs. There were few other distinguishing factors. The incidence of prior notification for abuse and neglect was four percent for the 'accident' group, 14% for the 'concern' group and 46% for the 'abuse/neglect' group. This is considerably higher in the 'concern' and 'abuse/neglect' groups than the annual state incidence of 1.73% for abuse and neglect notifications. While the clinical features of a burn may often not be helpful in reaching a diagnosis of abuse or neglect as a cause of the burn, it appears that many children who have non-accidental burns have also had prior notifications for other types of abuse or neglect.

Sexually abused children 5 years after presentation: a case-control study.

OBJECTIVE: A total of 68 sexually abused children and their nonoffending parents were reassessed 5 years after presentation and were compared with a cohort of children of similar age and sex who were not known to have been abused. METHOD: Outcome measures were behavior, depression, self-esteem, anxiety, eating problems, drug use, suicide attempts, self-injury, running away, criminal activity, and attributional style. Recent life events, demographics, family functioning, and mothers' mental health were taken into account when examining outcome. RESULTS: Although the abused children had experienced more negative life events, were from lower socioeconomic groups, had more changes in parent figures, and had mothers who were more psychologically distressed, multiple regression analysis showed that after allowing for these and other demographic factors, there were still significant differences between the groups after the 5 years. The abused children displayed more disturbed behavior, had lower self-esteem, were more depressed or unhappy, and were more anxious than controls. Sexually abused children had significantly higher levels of bingeing, self-injury, and suicide attempts. CONCLUSIONS: It is clear that many children who are sexually abused have ongoing problems. Their ongoing problems may be indicative of false beliefs about themselves and the sexual abuse experience.

Five years after child sexual abuse: persisting dysfunction and problems of prediction.

OBJECTIVE: To assess change in behavior, depression, and self-esteem in sexually abused children after 5 years and to determine which factors predict later functioning. METHOD: Sixty-eight of 84 children and their nonoffending parents were reassessed after 5 years for depression, self-esteem, and behavior problems in the children; parental mental health; and family functioning. RESULTS: There were no significant changes in depression, self-esteem, or behavior over 5 years. Forty-three percent of the children were now sad or depressed, 43% had low self-esteem, and 46% had behavioral dysfunction. While some children improved, a nearly equal number deteriorated, with no clear pattern of change. The only abuse-related variables associated with 5-year functioning were further contact with the abuser, which was significantly associated with depression and self-esteem, and sexual abuse prior to intake, which was related to an increased incidence of behavior problems. Older children showed more depression and lower self-esteem but less behavioral dysfunction. Poor family functioning at 5 years was associated with low self-esteem and behavior problems. Treatment had no effect on depression, self-esteem, or behavior. Multivariate analysis showed that depression and self-esteem at intake were prognostic indicators of 5-year outcome. CONCLUSION: Many sexually abused children have continuing problems with behavior, self-esteem, and depression. Family and abuse-related variables do not appear to be good predictors of outcome, although sexually abused children who are sad or depressed and have low self-esteem at intake are likely to have continuing problems in these areas.

Influential papers in child abuse.

A survey was conducted among professionals expert in the field of child protection to determine which papers or book chapters they felt had been the most influential. From their responses, a list of the 50 most mentioned papers and chapters was compiled. This list was sent to a large group of child protection professionals with the request that they rank the 15 publications which they considered most important. To compare the views of child protection professionals with the number of times these publications had been cited in the literature, a citation search was carried out. Kempe, Silverman, Steele, Droegemuller, and Silver's (1962) paper "The Battered Child Syndrome" and Summit's (1983) paper "The Child Sexual Abuse Accommodation Syndrome" received the highest ranking from the professionals. "The Battered Child Syndrome" also achieved the highest ranking in the citation search. Although there were a number of discrepancies between the professional rankings and the citation search, eight papers appeared in the top 15 rankings achieved by the professional survey and the citation search. Such a review of the influence of child abuse literature has limitations, although it does help to show which papers appear to have had an important and lasting influence.

Teaching children about skin cancer prevention: why wait for adolescence?

The baseline knowledge about skin cancer prevention of 983 children aged 8 to 12 years was assessed by a pretest questionnaire. After the pretest, half were given a formal presentation about skin cancer prevention. The other half participated in an informal, question-and-answer session, which covered all material from the formal presentation. Two weeks later, all students completed an identical post-test. The students had a high baseline level of knowledge about skin cancer prevention. Knowledge increased for most items in the post-test questionnaire. In all age groups there was no difference in results between the formal and interactive teaching sessions, except among eight-year-olds, for whom the formal presentation was more effective. As much solar skin damage occurs before adolescence, the younger age group is the important target for skin cancer prevention programs.

Velo-cardio-facial and partial DiGeorge phenotype in a child with interstitial deletion at 10p13--implications for cytogenetics and molecular biology.

We report on a female with a interstitial deletion of 10p13 and a phenotype similar to that seen with the 22q deletion syndromes (DiGeorge/velo-cardio-facial). She had a posterior cleft palate, perimembranous ventricular septal defect, dyscoordinate swallowing, T-cell subset abnormalities, small ears, maxillary and mandibular hypoplasia, broad nasal bridge, deficient alae nasi, contractures of fingers and developmental delay. This could indicate homology of some developmental genes at 22q and 10p so that patients with the velocardiofacial phenotype who do not prove to be deleted on 22q are candidates for a 10p deletion.

Stress and work relationships in the neonatal intensive care unit: are they worse than in the wards?

OBJECTIVE: To compare working conditions, sources of stress and professional relationships between a group of nurses working in neonatal intensive care units (ICU) and those working in general paediatric teaching hospital wards. METHODOLOGY: Surveys were sent to 96 nurses working in general paediatric wards in three Sydney paediatric teaching hospital centres and to 291 nurses working in six major neonatal ICU in Sydney. The survey asked about work environment, patient care, decision-making, sources of stress and professional relationships. Thirty-one questions were identical in each survey. The survey also included the General Health Questionnaire (GHQ) as a measure of emotional health. RESULTS: The response rate was ward nurses 86% and neonatal intensive care nurses 66%. Of the 31 identical statements, nine were significantly different between the two groups. Neonatal nurses were more likely to feel that their ward work areas were overcrowded and poorly laid out with little patient-free space. They had more concerns about inadequate staffing and conflict between nurses and doctors. The general ward nurses were more likely to feel that adequate priority was given to patient pain relief and that they had more influence in such decisions but experienced more stress in keeping up to date and were more likely to feel that communication problems between doctors and nurses were a major source of conflict. Forty per cent of general ward nurses and 32% of neonatal nurses had GHQ scores indicating possible psychological impairment, a significantly higher proportion than would be expected in the population. CONCLUSIONS: Paediatric nurses perceive a variety of stresses in their work, with problems in communication between doctors and nurses being a prominent perception. The high GHQ scores may be a reflection of some of those problems. Attention to problems of under-staffing, better work environment and improved communication may help resolve some of these issues and may have implications for improving patient care.

A therapeutic preschool for abused children: the KEEPSAFE Project. Kempe Early Education Project Serving Abused Families.

Twenty-four children attended a therapeutic preschool for physically and sexually abused children, the Kempe Early Education Project Serving Abused Families (KEEPSAFE), over a 3-year period from 1985-1988. The program provided early education and therapy for abused children so that they could improve developmentally, socially, and emotionally, with the aim that the children would be suitable to enter the public education system. The therapeutic preschool was combined with a home visitation program for the child's parents or primary caretaker, focusing on improving the quality of interaction between the adult and child. The majority of children made developmental gains at a faster rate than would normally be expected as measured by the McCarthy Scales of Children's Abilities and the Peabody Picture Vocabulary Test. Although all 24 children were thought at onset of intervention to be unable to participate in a public school setting, after 12 months in the program over 79% were staffed into the public school system eight (33.3%) into a regular classroom. Three others (12.5%) needed residential care, and two were too young to enter public school. Even though a therapeutic preschool is expensive in terms of the high staff to child ratio needed, it is likely to be beneficial in improving the developmental skills of abused children.

Self esteem, depression, behaviour and family functioning in sexually abused children.

Eighty-four sexually abused children and their families, were compared with controls to look at short-term effects of sexual abuse. The abuse group had more marital breakdown, unemployment, communication problems within the family and poor marital mental health. The abused children had more depression, low self-esteem and behaviour disorder. There was no relationship between intrafamilial abuse and depression, self-esteem or behaviour disorder. More severe abuse was related to low self-esteem and children's negative perceptions of their mothers. In planning treatment the child's relationship to the perpetrator may need less emphasis, with more on self-esteem, depression, family functioning and the child's perceptions of the family.

The relationship between intelligence and duration of circulatory arrest with deep hypothermia.

A total of 114 children (51 with tetralogy of Fallot, 30 with transposition of the great arteries, and 33 with ventricular septal defect) who had these defects repaired with the use of deep hypothermia and circulatory arrest were assessed for intellectual and neuropsychologic function at an average of 9 to 10 years after the operation. Children with preoperative intellectual handicaps or postoperative neurologic complications were excluded. These children were compared with 54 who had atrial septal defects repaired with the use of cardiopulmonary bypass. The only significant difference in the neuropsychologic measures was that the bypass group had reaction times 2 to 3 seconds shorter on average than those of the hypothermic circulatory arrest group. Although there was no significant difference in intelligence quotient between the groups, a relationship between intelligence quotient and arrest time was found. Regression analysis of intelligence quotient against duration of arrest showed a significant decrease in intelligence quotient with increasing arrest time (slope = -0.36; p = 0.002; 95% confidence interval, -0.59, -0.14) indicating a decrease of 3 to 4 intelligence quotient points for each extra 10 minutes of arrest time. It appears that deep hypothermia with circulatory arrest for cardiac operations in children does not fully protect the brain, with a linear relationship existing between the amount of impairment and the duration of circulatory arrest.

Herpes simplex virus infections in the neonate.

OBJECTIVE: To review the experience of the Camperdown Children's Hospital with neonatal herpes simplex viral (HSV) infections between 1960 and 1992. DESIGN: A retrospective record review of all cases of HSV infection. RESULTS: Fifteen proven HSV infections were found. Only three cases had a definite history of HSV infection during pregnancy. Six were delivered at 36 weeks gestation or earlier. Seven weighed 2500 g or less. Forty-three per cent developed physical signs within 7 days of birth. Three cases were confined to skin, eyes and mouth, five were generalized, six had encephalitis with or without skin lesions, and one had pneumonitis. The mortality rate comprising the five with generalized infection was 47%, one with encephalitis and the one with pneumonitis. Four of the eight survivors have persisting neurological impairment. Those with disseminated infection and encephalitis did poorly regardless of antiviral treatment. CONCLUSION: A high index of suspicion of HSV infection is important so that antiviral treatment can be commenced early, particularly for those infections localized to skin, eye and mouth where there may be a good prognosis.

Intellectual function and age of repair in cyanotic congenital heart disease.

Eighty one children, comprising 51 with tetralogy of Fallot and 30 children with transposition of the great arteries (TGA) were assessed using the Wechsler intelligence scale for children--revised, and a battery of neuropsychological measures. They were compared with a group of 33 children who had surgery for ventricular septal defect. All children were aged over 10 years when reviewed and were in good health, attending normal schools. No significant negative correlation was found between any component or subtest of the IQ scores and operating age. There was no evidence of a detrimental effect of older age at operation in the children who had cyanotic heart disease as assessed by neuropsychological measures. Delaying surgery for children with TGA or tetralogy of Fallot does not appear to adversely affect their intellectual development. This finding may provide reassurance in cases where surgery has to be delayed for medical, social, or economic reasons.