The mother-child interaction and clinical judgment during acute pediatric illnesses.

OBJECTIVES: For acutely ill children living in less than optimal environments, mothers and pediatricians may have a heightened perception of illness severity, a lower specificity of clinical judgments, and a tendency to over-utilize resources. We examined the mother-child interaction in order to understand the relation of less optimal environments to clinical judgment and resource use. STUDY DESIGN: At the 2-week and 6-, 15-, and 24-month well child visits of 316 children, the mother-well child interaction was assessed by using the Biringen's Emotional Availability Scales (EAS). Data were gathered regarding maternal depression and sense of competence, infant temperament, maternal social support, life events, the home environment, and demographics. At ill visits, the mother-ill child interaction was assessed by using the EAS, and mothers and pediatricians independently assessed illness severity using the Acute Illness Observation Scales. Resource use during the illness was evaluated. RESULTS: One thousand nine hundred eight-three acute illnesses were assessed. A less optimal mother-child interaction was significantly (P <.05 for all comparisons) associated with poorer reliability of mothers' judgments, lower specificity of mothers' judgments (71% vs 85%) and pediatricians' judgments (92% vs 97%), and greater use of resources (eg, for hospitalizations, 2.6% of visits vs 0.7%). Adverse maternal, infant, and demographic characteristics were associated with a less optimal mother-well child (r = 0.68) and mother-ill child (r = 0.80) interaction, a heightened perception of illness severity, and greater resource use. CONCLUSION: Less optimal environments adversely affect the mother-child interaction; a poor mother-child interaction is correlated with low specificity of clinical judgment and over-utilization of resources.

A putative poststreptococcal case of OCD with chronic tic disorder, not otherwise specified.

A 12-year-old girl presented with an atypical, recurrent, increasingly treatment-resistant case of obsessive-compulsive disorder and chronic tic disorder associated with profound separation anxiety, learning difficulty, and intermittent upper respiratory symptoms. In addition to detailed reviews of history and findings from many clinical caretakers from the prior 7 years, current pediatric, psychiatric, neuropsychological, neuroimaging, and clinical laboratory data were also available. Treatment options were considered from multiple perspectives: psychoanalytically oriented psychotherapy, conventional pharmacotherapy, family interventions, cognitive-behavioral therapy, and learning-supportive strategies. Psychological, neuropsychiatric, and neuroimmunological formulations of etiology were considered. Subsequent treatments included supportive psychotherapy, neuroleptic augmentation of selective serotonin reuptake inhibitors, prophylactic penicillin, and a course of six sessions of plasmapheresis over a 2-week period. The case raises questions for ongoing consideration that juxtapose dynamic, neuropsychiatric, and neuroimmunological perspectives.

Validation studies of Bilitec 2000: an ambulatory duodenogastric reflux monitoring system.

Bilitec 2000, a fiber-optic spectrophotometer, detects duodenogastric (DG) reflux in an ambulatory setting independent of pH by measuring bilirubin in bile. Studies were performed for independent validation and better understanding of limitations of this system. Bilitec and a conventional spectrophotometer were used to assess the effect of gastric acidity on the spectral absorbance of refluxed DG contents, employing bilirubin ditaurate (BDT) and human bile. Total bile acid concentrations correlated with Bilitec absorption. BDT and bile had hypsochromic shift (400 nm) in spectrophotometric maximum wavelength (lambda max; 450 nm) in an acidic environment (pH < 3.5), corresponding to an approximately 30% decrease in absorption measured by Bilitec. Bile acid concentrations correlated strongly with Bilitec absorption for all 63 samples (R = 0.82) with pH > 3.5 (n = 31, R = 0.81), but correlation was less strong for 32 samples with pH < 3.5 (R = 0.70). As currently designed, Bilitec adequately measures DG reflux but underestimates it by at least 30% in acidic medium (pH < 3.5). Design modifications are suggested for improving the sensitivity of this equipment.