THE CHALLENGE OF THE “WELL CHILD”

Upon general practitioners and pediatricians falls the responsibility of recognizing and treating most emotional problems in young children. This may be best carried out by the anticipation of expected problems, and the advance guidance or counseling of parents. That such problems are of high incidence was indicated in experience at a pediatric clinic where approximately 40 per cent of 7,000 children observed had psychosomatic symptoms.In order to utilize effectively the limited time available in office practice for Well Child care, a physician must have at hand certain basic information on personality development. Many of the normal behavior patterns in children which frequently are misinterpreted as “behavior problems” by parents are presented herein in chart form, divided into critical age periods, to help physicians quickly recognize what is normal and what abnormal in various periods of maximal crisis. Most of the problems of conflict within a child and of conflict between parents and child, it is felt, could be and should be handled at the pediatric level. Some seriously disturbed children need to be referred for psychiatric care. When this is necessary, skillful preparation of the parent and the child by the family physician for referral is most important to successful psychotherapy.     

Parents' experiences discussing pediatric vaccination with healthcare providers: a survey of Canadian naturopathic patients

Background

Parents who choose to selectively vaccinate or avoid vaccination for their children may do so at risk of compromising relations with their family physician or pediatrician. Groups that are associated with reduced rates of pedicatic vaccination, such as parents who access naturopathic care, may be particularly vulnerable to this issue.

Methodology/Principal Findings

In March through September 2010, we administered a 26-item cross-sectional survey to 129 adult patients, all of whom were parents with children ≤16 years of age, presenting for naturopathic care in Ontario, Canada. Ninety-five parents completed the survey (response rate 74%), and only 50.5% (48 of 95) reported that their children had received all recommended vaccines. Most parents (50.5%; 48 of 95) reported feeling pressure to vaccinate from their allopathic physician and, of those who discussed vaccination with their physician, 25.9% (21 of 81) were less comfortable continuing care as a result. Five percent (4 of 81) of respondents were advised by their physician that their children would be refused care if they decided against vaccination. In our adjusted generalized linear model, feeling pressure to vaccinate (odds ratio [OR] = 3.07; 95% confidence interval [CI] = 1.14 to 8.26) or endorsing a naturopathic physician as their most trusted source of information regarding vaccination (OR = 3.57; 95% CI = 1.22 to 10.44) were associated with greater odds of having a partially vaccinated or unvaccinated child. The majority (69.6%; 32 of 46) of parent''s with partially vaccinated or unvaccinated children reported a willingness to re-consider this decision.

Conclusions/Significance

Use of naturopathic care should be explored among parents in order to identify this high-risk group and engage them in discussion regarding pediatric vaccination to encourage evidence-based, shared decision making. Physicians should ensure that discussions regarding vaccination are respectful, even if parents are determined not to vaccinate their children.     

Childhood malignancies and decision making.

Failure to obtain "adequate" medical care for a child constitutes child neglect, which may be used as the basis for prosecution of parents, removal of the child from the home, or court-ordered medical treatment. "Adequate" care is usually construed as that which is given by a licensed physician, but, in case of dispute, courts almost never engage in choosing one medical approach over another. The principle that parents may not refuse medical care, however, is made very difficult when children have malignancies--the long-term nature of the treatment means that, if the child is left at home, court order or not, the parents may flee with their child. Removing the child from the home, however, adds that trauma to the ill child's burdens. Questions should be asked before making a request to a court to order a therapy which will prolong but not save a child's life if the parents would prefer to spare their child the side effects. Parents, however, may always refuse to permit their child to participate in research studies, no matter how promising. Adolescents are increasingly believed to be capable of medical decision making; most courts, however, would not allow an adolescent to refuse life-saving treatment.     

Do Characteristics of Parental Child Homicide in Sweden Fit Evolutionary Predictions?

Evolutionary models have been used to explain parental child homicide. One idea is that children with low fitness value to their parents will be less loved and cared for and therefore more at risk in conflict situations. It is then important to investigate if conflicts with the children are the major pattern in cases of parental child homicide. The aim of this study is to survey the background circumstances of parental child homicide in Sweden and relate them to the evolutionary model suggested. We more specifically investigate if the homicides occur in conflict situations with the child, the frequency of several victims (including the partner or former partner) and if there are differences in characteristics of homicides between stepparents and genetic parents. Our results show that parental child homicide is a heterogeneous phenomenon, where relatively few cases were the result of a conflict with the child‐victims. Instead severe conflicts between parents were the most common circumstance in which children were killed. Many children were victims of an extended suicide, which often included several members of the family. Step‐parents were more likely to kill children aggressively in conflicts with them than genetic parents. The complexity of the phenomenon suggests that an evolutionary model based upon a mechanism related to conflicts with the child‐victim has limited explanatory value on parental child homicide in general.     

Children in an ageing society

This paper explores the implications of demographic aging for children and pediatric practice in the Western society. It focuses on the social class differences in childbearing patterns, specific issues related to disability, and distribution of resources between age groups. Women in the Western world are now having children at an older age than at any time in the past 50 years. Voluntary childlessness or deliberate delay in childbearing is common among highly educated women. This changing pattern in childbearing may increase and polarize health and wealth inequalities. With advancements in neonatal and pediatric care which prolong life expectancy and survival of disabled children, it is projected that there will be an increasing number of very old parents caring for severely disabled offspring. Meanwhile, there are also many children who are carrying considerable burdens of caring for their disabled parents. The community burden of disability will continue to rise. The needs of the elderly population may drain resources from child health services. Despite this demographic pattern, care for the children is still important. Health care authorities must not become contented with the existing pediatric care services just because demographic changes require that the nation should invest more in care of the older population.     

Non-accidental injury in children: what we do in Derby.

A scheme for dealing with cases of non-accidental injury in children in the Derby clinical area has been operating since 1971. A stable team of doctors, policemen, and social workers deal with each case. The parents are told at once that battering is suspected, and the police and social services department co-operate closely in establishing the facts, supporting the family, and protecting the child. A psychiatric assessment of the parents may help social workers decide on the long-term care of the child, and the forensic physician is invaluable if the case has to go to court. The team has made three recommendations about prevention and management of these cases: a specialist social service team should be set up to deal with these children and regain the skills and knowledge lost when children''s departments were abolished in 1971; babies should be routinely weighed naked in infant welfare clinics; and juvenile courts should be able to order a psychiatric report on the parents in care proceedings.     

Femoral neck anteversion: values, development, measurement, common problems

The femoral neck anteversion angle is an important factor for hip stability and normal walking. It is multifactoral result of evolution, heredity, fetal development, intrauterine position, and mechanical forces. Abnormal FNA sometimes can be associated with many clinical problems ranging from harmless intoeing gait in the early childhood, to disabling osteoarthritis of the hip and the knee in the adults. In most cases is associated with minor functional problems in children during growth, but cause a concern in parents for children future. The child must be examined carefully and an accurate diagnosis must be established. The most important part of care is observation of the children. If abnormal femoral neck anteversion produces severe functional disability, derotational osteotomy should be done, but delayed until late childhood.     

Parents for children.

Parents for Children is a specialist adoption agency set up to find homes for children with special needs--that is, those with physical, mental, and emotional handicaps; older children; and sibling groups. Of the first 38 children placed, one child died and six placements broke down, although four children were later re-placed. Almost all the children referred to the agency had been in care for most of their lives. A full assessment of each child is necessary before placement, but in several cases the medical assessment in care had been inadequate. Many of the prospective parents themselves had serious medical conditions. The agency has proved that homes can be found for children in need, but there have been problems and parents require advice and support in the management of the children after placement.     

Chemotherapy versus supportive care alone in pediatric palliative care for cancer: comparing the preferences of parents and health care professionals

Background:

The choice between palliative chemotherapy (defined as the use of cytotoxic medications delivered intravenously for the purpose of our study) and supportive care alone is one of the most difficult decisions in pediatric oncology, yet little is known about the preferences of parents and health care professionals. We compared the strength of these preferences by considering children’s quality of life and survival time as key attributes. In addition, we identified factors associated with the reported preferences.

Methods:

We included parents of children whose cancer had no reasonable chance of being cured and health care professionals in pediatric oncology as participants in our study. We administered separate interviews to parents and to health care professionals. Visual analogue scales were shown to respondents to illustrate the anticipated level of the child’s quality of life, the expected duration of survival and the probability of cure (shown only to health care professionals). Respondents were then asked which treatment option they would favour given these baseline attributes. In addition, respondents reported what factors might affect such a decision and ranked all factors identified in order of importance. The primary measure was the desirability score for supportive care alone relative to palliative chemotherapy, as obtained using the threshold technique.

Results:

A total of 77 parents and 128 health care professionals participated in our study. Important factors influencing the decision between therapeutic options were child quality-of-life and survival time among both parents and health care professionals. Hope was particularly important to parents. Parents significantly favoured chemotherapy (42/77, 54.5%) compared with health care professionals (20/128, 15.6%; p < 0.0001). The opinions of the physician and child significantly influenced the parents’ desire for supportive care; for health care professionals, the opinions of parents and children were significant factors influencing this decision.

Interpretation:

Compared with health care professionals, parents more strongly favour aggressive treatment in the palliative phase and rank hope as a more important factor for making decisions about treatment. Understanding the differences between parents and health care professionals in the relative desirability of supportive care alone may aid in communication and improve end-of-life care for children with cancer.Despite the substantial improvements in rates of cure among children with cancer, some children will have progressive or recurrent disease and will die.¹ Cancer remains the second most common cause of death for North American children between 5 and 14 years of age.^2–4 When cure becomes unlikely, parents and health care professionals are often faced with the decision to continue further aggressive treatments or to provide relief from symptoms alone.¹The choice between palliative chemotherapy and supportive care alone is one of the most important and difficult decisions for parents of children whose disease cannot be cured.⁵ At this point, the goals of therapy are usually to maximize the child’s quality and length of life and to ensure respect for the family’s and child’s preferences.⁶Given the difficult nature of this decision, it is worthwhile to compare and contrast the perspectives of parents and health care professionals. Discordance in these perspectives could heighten the anxiety felt by patients and parents and might lead to their dissatisfaction with the care received. One qualitative study that interviewed parents of children with recurrent cancer found that “fearing disagreement with staff” was an important negative factor in decision-making.⁷ However, little is known as to whether the attitudes of parents and health care professionals toward therapeutic options are congruent.The goal of this study was to compare the strength of preference between parents and health care professionals for supportive care alone versus palliative chemotherapy for children whose cancer has no reasonable chance of being cured, and to determine how specific factors affect these preferences.     

To show our humanness--relational and communicative competence in pediatric palliative care

The death of a child is perhaps the worst tragedy a family ever has to endure. The communication that occurs among children, parents, and healthcare professionals at the end of a child's life must be grounded in caring, and compassionate relationships. These relationships require particular skills, knowledge and attitudes that are not fully addressed in many approaches to communication training currently available to practitioners. This essay proposes elements of a pedagogy for relational and communicative competence in pediatric palliative care that is rooted in ethical and ethnographic principles.     

Adoption and Children with Learning and Behavior Problems

One representative case study is used to illustrate the complex interaction of factors that can lead to tragic family dysfunction when an adopted child has learning and behavior problems. The presence of neurodevelopmental problems in an adopted child, special adoption issues and interparental and intraparental conflicts combine to place the child and his family at high risk. The child''s neurodevelopmental difficulties are expressed primarily as subtle learning and behavior problems which make him a focus for parental conflict. In addition, the adoption issues of difference, impermanence, feelings of mutual obligation and fear of abandonment are generally poorly understood and form the basis for the development of unique interactional patterns of communication. Finally, in the families studied, it was often found that the adopting parents had serious personal and/or marital difficulties.     

THE MISTREATED CHILD

“The battered child” has recently attracted the attention of physicians and social workers, but despite the fact that inflicted trauma produces characteristic x-ray changes, physicians are often reluctant to admit this cause. The neglected child may be more difficult to diagnose and is probably more common. The most typical example is the infant who is admitted to the hospital for “failure to thrive,” yet gains weight rapidly while away from his parents.The parents of both types of children are likely to be immature and inadequate, but much more study is required before the factors common to these parents are known, to say nothing of the means required for prevention and treatment.When the physician suspects that the parent is causing the difficulties manifested by the child, he should seek the help of a social worker in clarifying the situation and in contacting the appropriate social or legal agency. A greater awareness of the problems of these children should result in more rapid recognition of the condition, the establishment of well-defined methods of handling such cases, and ultimately better legislation to safeguard the child''s rights to a safe and healthy childhood.     

Postnatal Environmental Tobacco Smoke Exposure Related to Behavioral Problems in Children

ObjectiveThe purpose of this study was to examine the association between pre and post environmental tobacco smoke (ETS) exposure and behavioral problems in schoolchildren.MethodsIn the cross-sectional 6 cities Study conducted in France, 5221 primary school children were investigated. Pre- and postnatal exposure to secondhand tobacco smoke at home was assessed using a parent questionnaire. Child’s behavioral outcomes (emotional symptoms and conduct problems) were evaluated by the Strengths and Difficulties Questionnaire (SDQ) completed by the parents.ResultsETS exposure during the postnatal period and during both pre- and postnatal periods was associated with behavioral problems in children. Abnormal emotional symptoms (internalizing problems) were related to ETS exposure in children who were exposed during the pre- and postnatal periods with an OR of 1.72 (95% Confidence Interval (CI)= 1.36-2.17), whereas the OR was estimated to be 1.38 (95% CI= 1.12-1.69) in the case of postnatal exposure only. Abnormal conduct problems (externalizing problems) were related to ETS exposure in children who were exposed during the pre- and postnatal periods with an OR of 1.94 (95% CI= 1.51-2.50), whereas the OR was estimated to be 1.47 (95% CI=1.17-1.84) in the case of postnatal exposure only. Effect estimates were adjusted for gender, study center, ethnic origin, child age, low parental education, current physician diagnosed asthma, siblings, preterm birth and single parenthood.ConclusionPostnatal ETS exposure, alone or in association with prenatal exposure, increases the risk of behavioral problems in school-age children.     

Coercive restraint therapies: a dangerous alternative mental health intervention

Physicians caring for adopted or foster children should be aware of the use of coercive restraint therapy (CRT) practices by parents and mental health practitioners. CRT is defined as a mental health intervention involving physical restraint and is used in adoptive or foster families with the intention of increasing emotional attachment to parents. Coercive restraint therapy parenting (CRTP) is a set of child care practices adjuvant to CRT. CRT and CRTP have been associated with child deaths and poor growth. Examination of the CRT literature shows a conflict with accepted practice, an unusual theoretic basis, and an absence of empirical support. Nevertheless, CRT appears to be increasing in popularity. This article discusses possible reasons for the increase, and offers suggestions for professional responses to the CRT problem.     

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background

Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.

Methods

We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.

Results

Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).

Conclusions

Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.     

Parent–offspring transaction: Mechanisms and the value of within family designs

This article is part of a Special Issue “Parental Care”. Parenting is best understood as a transactional process between parents and their offspring. Each responds to cues in the other, adapting their own behavior to that of their partner. One of the goals of parenting research in the past twenty years has been to untangle reciprocal processes between parents and children in order to specify what comes from the child (child effects) and what comes from the parent (parent effects). Child effects have been found to relate to genetic, pre and perinatal, family-wide, and child-specific environmental influences. Parent effects relate to stresses in the current context (e.g. financial strain, marital conflict), personality and ethnicity but also to adverse childhood experiences (e.g. parental mental health and substance abuse, poverty, divorce). Rodent models have allowed for the specification of biological mechanisms in parent and child effects, including neurobiological and genomic mechanisms, and of the causal role of environmental experience on outcomes for offspring through random assignment of offspring–mother groupings. One of the methods that have been developed in the human and animal models to differentiate between parent and child effects has been to study multiple offspring in the family. By holding the parent steady, and studying different offspring, we can examine the similarities and differences in how parents parent multiple offspring. Studies have distinguished between family average parenting, child-specific parenting and family-wide dispersion (the within family standard deviation). These different aspects of parenting have been differentially linked to offspring behavioral phenotypes.     

DELINQUENCY

Not all behavior problems develop into juvenile delinquency nor do all juvenile delinquents become adult criminals. Environment is not in itself the only determining factor in the development of delinquency; rather, environment may offer the opportunity for acting out conflicts in an antisocial way. Conflicts are dealt with by antisocial behavior patterns rather than through various neurotic defense mechanisms. There appears to be a defect in conscience.Parental roles are extremely important in helping the growing child develop those positive aspects of his personality which lead to adult maturity and adult happiness. Included in parental factors are the relationships of both parents to the child, not just in what is conscious and deliberate in the relationship, but in what also can occur unconsciously or without awareness in the relationship.     

Delinquency

Not all behavior problems develop into juvenile delinquency nor do all juvenile delinquents become adult criminals. Environment is not in itself the only determining factor in the development of delinquency; rather, environment may offer the opportunity for acting out conflicts in an antisocial way. Conflicts are dealt with by antisocial behavior patterns rather than through various neurotic defense mechanisms. There appears to be a defect in conscience. Parental roles are extremely important in helping the growing child develop those positive aspects of his personality which lead to adult maturity and adult happiness. Included in parental factors are the relationships of both parents to the child, not just in what is conscious and deliberate in the relationship, but in what also can occur unconsciously or without awareness in the relationship.     

Adaptation of children to a chronically ill or mentally handicapped sibling.

The presence of a chronically ill or mentally handicapped child in a family can be a stress for the child''s siblings, who often are ill informed about the nature and prognosis of the illness, may be uncertain what is expected of them in the caregiving role, may feel their own identities threatened, and may experience ostracism by their friends and misunderstanding at school. Although individual reactions vary widely, feelings of anger, guilt, resentment and shame are commonly reported. Excessive responsibility and concern about one''s identity may add to these feelings and culminate in psychologic problems in the sibling. The physician caring for the family must be alert for symptoms of emotional disturbance or social maladjustment among the siblings of chronically ill or mentally handicapped children and should be prepared to counsel the family or refer them to a counsellor experienced in this area. In general, the first step is to be sure that the sibling is fully informed about the condition and to encourage frank discussion between the parents and the handicapped child''s siblings.