Pediatric bone marrow transplants: psychological aspects.

On a pediatric bone marrow transplant unit, hematologist-oncologists, nurses, social workers, psychiatrists, psychologists, and others on the team deal with children and adolescents whose cancers are either treatable by marrow transplantation or are ultimately fatal. Contrary to original assumptions, many children and families cope well, especially in relatively uncomplicated cases with good outcome. Treatment may include direct psychotherapeutic intervention with the child and family, as well as use of psychopharmacologic agents such as antidepressants or anxiolytics for frank psychiatric disorders. Psychotherapists often have to function adjunctively with other staff members in their interactions with the patient and the family. A stress disorder model appears to best explain child, parent and family reactions to bone marrow transplantation. Given the medical severity and complexity of the conditions treated, and the approximately equal rates of overall success and failure, a supportive consultative approach is usually most helpful for child patients, parents and staff throughout the procedure. A retrospective study of the children treated over seven years in a tertiary pediatric hospital bone marrow transplant unit is presented. The level of child, parent, and family psychopathology was usually mild to moderate, but there were clear differences between patients. Mothers were more supportive than fathers under this extreme type of stress. Prospective longitudinal studies of children and families are needed to establish causal chains and optimal therapeutic interventions.

On the usefulness of the DSM-III-R versus the DSM-III for child psychiatrists.

The purpose of this paper is to compare and contrast the disorders of infancy, childhood and adolescence in the DSM-III-R with those of its predecessor, the DSM-III. Design features of the child psychiatry sections of the DSM-III-R are described, with comparisons of reliability and validity assessments in the two classifications. Categorical and dimensional systems of psychiatric nosology are described; the DSM-III-R has features of both systems. To be most useful for child psychiatrists in ordinary clinical practice, DSM-III-R symptom criteria should be available in a standardized but brief fashion to ensure adequate data gathering from both child and parent. This avoids problems inherent in lengthy standardized interviews are based on DSM-III-R criteria; although these interviews are excellent for research purposes, clinicians tend to avoid them as clinically constraining. The commonly used alternate of clinicians' overall evaluations is of uncertain reliability and validity, since it is unclear whether all symptoms have been asked for. A symptom checklist approach is therefore suggested as a intermediate procedure to ensure that appropriate questions are asked from the parent and child, while allowing fuller exploration by the clinician. This approach also indicates parent-child variance, and allows for rank ordering of diagnoses which may indicate priorities for treatment of child psychiatric disorders. Overall, the DSM-III-R is a positive step towards more adequate diagnosis and treatment for child and adolescent psychiatric disorders, which will lead to further improvement in the future DSM-IV.

Neurologic status and intracranial hemorrhage in very-low-birth-weight preterm infants. Outcome at 1 year and 5 years.

Twenty-six very-low-birth-weight preterm infants with and without intracranial hemorrhage (ICH) were followed up prospectively from birth to school age to determine the relationship between ICH and subsequent neurologic and cognitive outcomes. All children had sequential cranial ultrasound examinations at birth and neurologic assessments at 3-month intervals during the first year, at 1 year of age, and at 5 to 6 years; psychometric assessments were done at 5 to 6 years. Seventeen children had no ICH, 3 had grade 1 ICH, 1 had grade 3 ICH, and 5 had grade 4 ICH. The 1-year Amiel-Tison neurologic assessment in 25 infants demonstrated that 14 were normal, 3 were suspect, and 8 were abnormal. By 5 to 6 years of age, 5 of 8 children neurologically abnormal at 1 year remained abnormal, 2 of 3 children neurologically suspect at 1 year remained suspect; while 9 of 15 children neurologically normal at 1 year remained normal, the remaining 6 had become suspect. The predominant neurologic abnormality at 5 to 6 years was subtle neurologic dysfunctioning. The Wechsler Preschool and Primary Scale of Intelligence at 5 to 6 years revealed a mean group IQ score of 92.1. The Beery Visual Motor Integration Test results demonstrated that 18 of 26 children had mild to severe visual motor perceptual difficulties. Severe ICH (grades 3 and 4) correlated with abnormal neurologic performances at 1 and 5 to 6 years. Mild ICH (grade 1) and no ICH did not correlate with any one of the 1-year neurologic classifications. The 1-year status correlated with the 5- to 6-year neurologic outcome best for children who were either neurologically suspect or abnormal at age 1 year. The 1-year neurologic score did not correlate with 5- to 6-year IQ and Beery Visual Motor Integration Test scores.