Management of diabetes mellitus in children.

In many respects the management of diabetes mellitus in children differs from the management in adults. Guidelines for the short- and long-term management of the child with diabetes mellitus, particularly as it relates to clinical presentation, treatment of ketoacidosis, long-term therapy and psychological counseling, are presented. The specific aspects of diabetes management that are unique to the child are best met by an increased understanding of the problems by the child and the family and an integrated approach by the physician and allied health personnel.     

Psychosoziale Belastungen, familiäre Konflikte und Therapieverantwortung bei Diabetes im Kindes- und Jugendalter

Children and youth with type 1 diabetes show an enhanced prevalence of psychiatric disorders, especially depression and eating disorders. Their parents suffer from constant vigilance, fear of hypoglycaemia and worries about their child’s future. Children’s quality of life corresponds largely to the quality of life of healthy peers, but is influenced by glycemic control and family conflicts. Illness related family conflicts increase in adolescence, when parental supervision of diabetes therapy run contrary to adolescents’ needs of autonomy. A stepwise transfer of treatment responsibility, which is adjusted to the child’s developmental status, should begin in adolescence at the earliest. The psychosocial care of patient families from diagnosis on should be an integral part of treatment and include patient education programs as well as psychological single case and group intervention.     

Counselling the parents of handicapped children.

The parents of handicapped children have to adjust to a wide variety of emotional and psychological problems when first confronted with the failure of their reproductive expectations. Counselling is a formal procedure or transaction in which both counsellor and parents aim to find a mutually acceptable plan of adjustment. Parents may need support to cope with their own personal inadequacies as well as with their own personal inadequacies as well as with the needs of the child. Counselling should be a continuous process, in which the parents can learn to accept the child as a different rather than a lesser person.     

Mothers,Fathers, Families,and Circumstances: Factors Affecting Children's Adjustment

The burgeoning empirical literature exploring the factors accounting for individual differences in psychological adjustment is reviewed. Many studies have shown that adjustment is largely affected by differences in the quality of parenting and parent–child relationships, the quality of the relationships between the parents, and the richness of the economic and social resources available to the family; more recent research signals the importance of congenital differences as well. Dimensions of family structure—including such factors as divorce, single parenthood, and the parents' sexual orientation—and biological relatedness between parents and children are of little or no predictive importance once the process variables are taken into account, because the same factors explain child adjustment regardless of family structure. These findings have important social and legal implications, especially in relation to decisions regarding foster care and adoption, as well as those concerning children's well-being following family dissolution.     

Impact of Father Involvement: A Closer Look at Indirect Effects Models Involving Marriage and Child Adjustment

In this article we present a framework for understanding the indirect effects of fathering on child development in the context of the marriage. We discuss three central pathways of influence: through relations between marital quality and fathering, through children's exposure to father expressions of marital discord, and through relations between marital quality and father psychological functioning. We provide corresponding hypotheses and review recent research to support or refute each. A common theme is that fathers, as well as mothers, have important influences in marital contexts, with some evidence for different or even greater impact of fathers in terms of the relations between the marital relationship and parenting, the impact of child exposure to marital conflict expressions, and as a function of parental symptomatology, although these effects are often complex. We discuss the value of including fathers in research on families and child development, and point out some promising directions for future study.     

Psychological complications after stillbirth--influence of memories and immediate management: population based study.

OBJECTIVE--To identify factors that may predict long term psychological complications among women who have had a stillborn child. DESIGN--Nationwide population based study using epidemiological methods. SUBJECTS--380 subjects and 379 controls who had had a stillborn or non-deformed live child in Sweden in 1991. RESULTS--Information was provided by 636 (84%) women. The ratio (95% confidence interval) of proportions of women with symptoms related to anxiety above the 90th centile for women who had had a stillborn child compared with those who had not was 2.1 (1.2 to 3.9). An interval of 25 hours or more from the diagnosis of death in utero to the start of delivery gave a ratio of 4.8 (1.5 to 15.9). The ratio was 2.3 (1.1 to 5.3) for not seeing the child as long as the mother had wished and 3.1 (1.6 to 6.0) for no possession of a token of remembrance. CONCLUSION--It is advisable to induce the delivery as soon as feasible after the diagnosis of death in utero. A calm environment for the woman to spend as much time as she wants with her stillborn child is beneficial, and tokens of remembrance should be collected.     

Quelle information donner �� une femme souffrant de troubles psychotiques ou de troubles bipolaires avant la naissance d��un enfant ?

What information should be provided to a female patient suffering from a psychotic disorder or a bipolar disorder prior to the birth of her child? Pregnancy is a time of intense psychological reshuffles that may weaken parents-to-be. The couple or the mother-to-be will seek the support of their loved ones. In this particular time, the involvement of professionals may be necessary when difficulties arise for the couple in relation to the psychological adjustment required by a child??s arrival. In case of a pregnancy contemplated in women affected by a mental illness, information related to potential risks carried by treatments and also by the impact of the pregnancy itself, the eventuality of the inability, for a more or less long period of time, to look after the child as well as the occurrence of possible distortions of the interactions in this context must be discussed in each parental project. This consists of a reflection on the benefits/risks by the patient, if possible her partner, also involving the referring psychiatrist, the general practitioner, the obstetricians and the paediatricians. This information is not always easy for the referring psychiatric to deliver. A tight cooperation between the Department of General Psychiatry and the Departments of Infant-Juvenile Psychiatry is important from a perspective of prevention, as it is required to deal with the perinatal/prenatal issues which arise out of the formation of a quality bond between mentally ill parents and a baby, that is sometimes difficult to set in place by the professionals involved and also by the patients themselves at the time of the birth. Thus, Cico was set up at the Saint Anne Hospital, non sectored, dealing with child psychiatric and adult psychiatric approaches. It allows patients to reflect on their desire for a child and provides information on the course of pregnancy to patients. It also assesses the capacity of the patient to form a bond with the child.     

Pédiatrie nucléaire : applications en oncologie

While nuclear pediatrics, as well as radio-pediatrics for radiology, should be considered as a full specialty of nuclear medicine, oncology applications also deserve special consideration. The child indeed is not a miniature adult, and especially in oncology, we must take into account the specificity of various diseases, the management of pain, and the fundamental psychological involvement of the disease in the child but also in his family. In this presentation, we wanted to address key information and methodological approaches of specific diagnostic tests, emphasizing the peculiarities of this specialty.     

Philosophy behind science. Confirming affectivity, the dawn of human life: the pre-, peri- and postnatal affective-confirming. Haptonomic accompaniment of parents and their child

This article gives a short introduction to the science of Haptonomy and more specially to the application of its specific phenomenality of psychotactile affective contact and interaction during prenatal and postnatal life and during childbirth. The neurophysiological implications and the influence of this approach on the pain threshold are briefly mentioned, as well as psychological influences on the postnatal development of the child. Finally, there is a critical commentary on the use of the ultra-sound scan.     

Obtaining the child testimony in the criminal proceedings

Children fall under the special category of vulnerable witnesses. Children's vulnerability is the reason that we must approach obtaining the child's testimony in the criminal proceedings with special attention. It is important to take the child's testimony as soon as possible and to avoid the repetition of interrogation. The criminal proceedings law and the juvenile court law enable children interrogation through the professional person without the presence of other parties in the procedure and enable the recording of such interrogation by audio-video link which considerably diminish the secondary victimization. The professionals who obtain the testimony must be well acquainted with children's psychological development. Knowledge of psychological development is of major importance in order to make the quality arrangements for interrogation and to interrogate the child and to achieve positive social contact between the examiner and the examinee and it is also of great importance for the credibility evaluation of the child's testimony. The adequate way of children interrogation will enable the child to say the correct information and to recognize the perpetrator. The forensic interview is well elaborated and child adapted technique of interrogation. Respecting the rules of forensic interview will enable the child's testimony on court to be relevant evidence.     

Logical-Semantic Analysis and the Development of L.S. Vygotsky's Ideas About “Units” and “Elements” of Psychological Systems

Based on an analysis of L.S. Vygotsky's concepts of “units” and “elements” of psychological systems, this article highlights five of their attributes. It shows that these attributes are logically symmetrical, since in their wording they can be converted into one another by negation or by replacing some words with their opposites. This suggests that the concepts of the “unit” and “element” of a system are different poles of one theoretical construct of the activity of human psychology. Thus methods for the study of psychological systems by breaking them down into elements or by separating them into units can be seen as complementary. The article describes differences among the concepts of “unit,” “minimal unit,” and “cell” of a psychological system. It reviews several problems that are solvable using the “method of units,” as well as some concepts of the theory of psychological systems that are understood as holistic, conceptual, and active processes and/or results of human interaction with the world. Among the examples of such systems are “systems of psychological functions” (according to Vygotsky), as well as separate activities (according to A.N. Leontiev), human actions and operations (interactions with the world on the level of objects and mental or physical means). The “component” of a psychological system is defined as any “something” that in some sense belongs to or is included in human interaction with the world. A component that belongs to the system is called an “element” of it, but a component that is included in the functioning and development of the system is called a “part” of it. The article presents the mathematical and psychological foundation of these definitions. It identifies and discusses the substantial (independently existing) components of psychological systems and their attributes (properties and conditions). It describes the relationships between them using the bipolar theoretical constructs “part-element” and “substantial-attributive” component of a system.     

Association between maternal and child leptin levels 9 years after pregnancy complicated by gestational diabetes.

Obesity is a state of relative leptin resistance, and obesity in childhood is associated with an increased incidence of type 2 diabetes in later life. Offspring of mothers with gestational diabetes mellitus (GDM) are at increased risk of obesity. A cohort consisting of 64 mothers, 33 GDM and 31 controls screened for diabetes during the index pregnancy together with their 9-year-old offspring were studied. Our hypotheses were: 1) an elevated child leptin is associated with elevated maternal leptin in GDM mothers 9 years post delivery; and 2) child leptin at 9 years serves as a marker for incipient insulin resistance. By univariate analyses, child leptins were only significantly correlated with maternal leptins among the offspring of GDMs (OGDM) (r = 0.59; p = 0.001). By multivariate analyses, child leptin for the total study group was significantly associated with child body mass index (BMI) (R(2) = 0.65; p < 0.0001), child fasting insulin (R(2) = 0.08; p = 0.03), and female gender (R(2) = 0.28; p = 0.001). In addition, among OGDM child leptin was associated with maternal leptin (R(2) = 0.14; p = 0.005). Our results suggest that there is an association between maternal and child leptin levels 9 years after a pregnancy complicated by gestational diabetes.     

Psychologische Aspekte des Diabetes in Kindheit und Adoleszenz

The intensified insulin therapy of type 1 diabetes imposes considerable demands in everyday life of children, adolescents and their families that often interfere with normal developmental tasks. Accordingly current guidelines on paediatric diabetes stated that psychosocial factors are the most important influences affecting the care and management of the chronic illness. This article reviews the main research findings from studies on psychological coping, family burden and dynamics, neurocognitive functioning, stress, psychosocial risk factors, psychological health and psychiatric disorders. In addition psychological support, age-appropriate educational and behavioural interventions as an integral part of every type 1 diabetes long-term therapy are described. Finally the vital role and the current situation of psychologists and social workers as members of the interdisciplinary paediatric diabetes teams especially in the context of the German Disease –Management Program for type 1 diabetes are discussed.     

The problem of the poor reader

Children who are retarded readers may present a complex problem involving physical impediments, emotional distress, or teaching methods. A child with specific reading disability has spatial confusion, an exaggeration or persistence of a normal childhood tendency to reversal of letters and symbols, ambidexterity, normal intelligence, and poor visual recall of words. Children with these characteristics fail to learn to read in a teaching system in which the main emphasis is on visual associations. Treatment of such reading difficulties, as well as prophylactic measures, is outlined.     

Situating stress: lessons from lay discourses on diabetes

In response to the serious toll diabetes takes on health and resources, researchers increasingly are examining physical and psychological pathways that affect and are affected by diabetes, including stress. Although biomedical researchers and practitioners are beginning to recognize the association between stress and diabetes onset and management, laypersons have long-standing and extensive insights into the multiple ways in which stress is associated with the diabetes disease process. In this article, we examine lay perspectives on stress and diabetes among a multiethnic sample of 80 adults. Participants suggest varying arenas in which stress intersects with diabetes, including stress as implicated in the origin of diabetes, as a threat to maintaining glycemic control, as a challenge to self-management, and as a precursor to and a consequence of diabetes complications. An improved understanding of such perspectives may enhance appropriate disease management and develop a more valid conceptualization of stress in research efforts.     

PSYCHIATRIC MANAGEMENT OF INTERSEXED PATIENTS

The psychiatric management of intersexed patients stems from an awareness that sexual identity is the result of a complex mixture of somatic and psychological components. Decisions in treatment are dependent on the appearance and correctability of the anatomic defects, the age of the patient, and the potential reversibility of the identifications contributing to the manifested sexual identity. In infants and small children, following proper diagnosis of somatic sex and an evaluation of degree of correctability of anatomical defects, decision can be made whether to bring up the child in his genetic sex or not. It is very difficult to change the sexual identity after two and a half years, except possibly in persons who already have considerable question as to their maleness or femaleness.In the psychiatric treatment of children with such disorders, the child and his family should be informed in understandable language what is being done, and the child and usually the parents should be involved in psychotherapy.With the adult, if treatment is necessary, supportive therapy, not psychoanalysis, should be used.     

Symptoms of Emotional,Behavioral, and Social Difficulties in the Danish Population of Children and Adolescents with Type 1 Diabetes – Results of a National Survey

Objective

To assess the prevalence of psychological difficulties in Danish children and adolescents with type 1 diabetes using both child/adolescent and caregiver reports, and to investigate associations between these symptoms and metabolic control, adherence, and quality of life.

Research Design and Method:

A total of 786 children and adolescents (8–17 years) recruited through the Danish Registry of Childhood Diabetes completed subscales of the Beck''s Youth Inventories (BYI-Y), while 910 caregivers completed the Strength and Difficulties Questionnaire (SDQ). The participants also completed questionnaires assessing adherence and quality of life. BYI-Y and SDQ responses were compared with results from normative samples.

Results

Children with diabetes generally reported a lower level of symptoms of depression and anxiety, while older adolescents in most cases were comparable to the normative samples. However, the numbers of patients with elevated scores were similar to normative groups, especially regarding the proportion of participants with ‘Extremely elevated’ scores. Caregivers of children and adolescents with diabetes generally reported the prevalence of elevated scores on the SDQ to exceed the prevalence observed in the norm sample – particularly with regard to older boys. Both BYI-Y and SDQ responses were significantly correlated with HbA_1c, adherence, and quality of life.

Conclusions

This study finds Danish children and adolescents with diabetes to report lower or comparable levels of emotional difficulties compared to norms, while caregiver reports are less positive. The results therefore support the value of a multi-informant approach to the assessment of symptoms of psychological difficulty in girls and boys with diabetes.     

What Is the Best NGS Enrichment Method for the Molecular Diagnosis of Monogenic Diabetes and Obesity?

Molecular diagnosis of monogenic diabetes and obesity is of paramount importance for both the patient and society, as it can result in personalized medicine associated with a better life and it eventually saves health care spending. Genetic clinical laboratories are currently switching from Sanger sequencing to next-generation sequencing (NGS) approaches but choosing the optimal protocols is not easy. Here, we compared the sequencing coverage of 43 genes involved in monogenic forms of diabetes and obesity, and variant detection rates, resulting from four enrichment methods based on the sonication of DNA (Agilent SureSelect, RainDance technologies), or using enzymes for DNA fragmentation (Illumina Nextera, Agilent HaloPlex). We analyzed coding exons and untranslated regions of the 43 genes involved in monogenic diabetes and obesity. We found that none of the methods achieves yet full sequencing of the gene targets. Nonetheless, the RainDance, SureSelect and HaloPlex enrichment methods led to the best sequencing coverage of the targets; while the Nextera method resulted in the poorest sequencing coverage. Although the sequencing coverage was high, we unexpectedly found that the HaloPlex method missed 20% of variants detected by the three other methods and Nextera missed 10%. The question of which NGS technique for genetic diagnosis yields the highest diagnosis rate is frequently discussed in the literature and the response is still unclear. Here, we showed that the RainDance enrichment method as well as SureSelect, which are both based on the sonication of DNA, resulted in a good sequencing quality and variant detection, while the use of enzymes to fragment DNA (HaloPlex or Nextera) might not be the best strategy to get an accurate sequencing.     

Bayesian interval estimation of genetic relationships: application to paternity testing.

Using genetic marker data, we have developed a general methodology for estimating genetic relationships between a set of individuals. The purpose of this paper is to illustrate the practical utility of these methods as applied to the problem of paternity testing. Bayesian methods are used to compute the posterior probability distribution of the genetic relationship parameters. Use of an interval-estimation approach rather than a hypothesis-testing one avoids the problem of the specification of an appropriate null hypothesis in calculating the probability of paternity. Monte Carlo methods are used to evaluate the utility of two sets of genetic markers in obtaining suitably precise estimates of genetic relationship as well as the effect of the prior distribution chosen. Results indicate that with currently available markers a "true" father may be reliably distinguished from any other genetic relationship to the child and that with a reasonable number of markers one can often discriminate between an unrelated individual and one with a second-degree relationship to the child.     

Insulin treatment at onset of diabetes. Leicester Royal Infirmary Children's Hospital, Leicester, UK

Management strategies and practicalities of insulin therapy in the first days and weeks after the diagnosis of diabetes in children and adolescents depend on the clinical situation and the facilities available. Outpatient or domiciliary management favoured by some centres is only practicable and safe if an experienced team is readily available. There is evidence showing a correlation between the level of glycaemic control achieved in the earliest years of treatment and the metabolic control in subsequent years (the 'tracking phenomenon'). The major factors influencing metabolic control in the first year after diagnosis certainly include the continuing secretion of endogenous pancreatic insulin. There has been considerable debate as to whether continuing insulin secretion and the induction of the remission phase can be significantly affected by the methods of insulin administration in the first days after clinical diagnosis; whether intravenous insulin has a protective effect; whether psychosocial factors have a more profound influence on metabolic control; and whether there is enough evidence to make valid recommendations on the optimal method(s) for treating children at the onset of diabetes. It seems likely that from the first day after diagnosis benefit is derived from attempting to obtain near normoglycaemia and the rapid induction of a partial remission phase by whatever insulin regimen is found to be most successful. This may occur not only by reducing the threat of glucotoxicity on the beta-cells but also by setting a pattern of optimal control for the child and the family. This process is enhanced by frequent contact with the team of experts in childhood diabetes who are able to give advice on insulin adjustments from the onset of diabetes.