Alan Ross

NORMAL GROSS MOTOR DEVELOPMENT: THE INFLUENCES OF RACE, SEX AND SOCIO-ECONOMIC STATUS

The ages at attainment of 12 gross motor milestones were obtained prospectively during well‐baby visits in the first two years of life for 381 children. All had been born at term and were judged to be normal at one year. A longitudinal analysis, using an index summarising each chilďs progress for eight selected milestones, is reported for the 284 children for whom data were complete. A high percentage of parents were able to report the age at attaining milestones with an acceptable degree of variability. The children attained milestones at earlier ages than traditionally reported. There were only minor sex differences in age at attainment, but black children attained milestones earlier than white children.

Clinical linguistic and auditory milestone scale: prediction of cognition in infancy.

At each well‐child examination between birth and two years, parents of 448 infants were questioned about their childs age at attainment of 25 linguistic and auditory milestones. Parental reports were compared with the results of independently administered Bayley Mental Developmental Index (MDI) at one year of age. Parental recall of information was high, ranging from 70 to 99 per cent for 21 of the 25 milestones. The milestone performance of infants with normal MDI scores showed an orderly, sequential progression of expressive and receptive language. Across the entire population studied, the correlation between milestone attainment and MDI was statistically significant for 24 of the 25 milestones, and later attainment of milestones correlated with lower MDI. As a group, ‘delayed’ infants (MDI <68) attained milestones significantly later than ‘average’ infants (MDI 85 to 116) for 20 of 25 items. Attention to linguistic and auditory milestones early in infancy can contribute to the early detection and diagnosis of mental retardation and disorders of communication.

Relation of BMI to a dual-energy X-ray absorptiometry measure of fatness

Dual-energy X-ray absorptiometry (DXA) is a valid technique for measuring the fat, bone and lean (muscle, organs and water) masses of the body. We evaluated relationships of BMI (kg/m2) with independent measurements of fat and lean masses using DXA in 226 adult volunteers. The evaluation was an application of a general approach to compositional data which has not previously been used for describing body composition. Using traditional regression analyses, when lean mass was held constant, BMI varied with fat mass (men r 0.75, P < 0.05; women r 0.85, P < 0.05); when fat mass was held constant, BMI varied with lean mass (men r 0.63, P < 0.05; women r 0.47, P < 0.05). In contrast, a regression model for compositional data revealed that BMI was: (a) strongly associated with log fat mass in both sexes (b1 4.86, P < 0.001 for all women and b1 5.96, P < 0.001 for all men); (b) not associated with bone mass, except in older men; (c) related to lean mass in women but not in men (b3 -4.04, P < 0.001 for all women and b1 -2.59, P < 0.15 for all men). Women with higher BMI tended to have more fat mass and more lean mass than women with lower BMI. Men with higher BMI had more fat mass but similar lean mass to men with lower BMI. Investigators need to be alert to the inaccuracy of BMI to assign a fatness risk factor to individuals, especially among women.

A study of pregnancy outcomes in a maternity center and a tertiary care hospital.

This study compares 796 pregnancy outcomes at a maternity center (BMC) with 804 hospital (TJUH) pregnancy outcomes. The samples of pregnant women from the participating institutions were matched on sociodemographic characteristics; analysis of outcomes was performed controlling for medical-obstetric risk. Differences between the institutions were found mainly among women with low intrapartum risk. For these women, neonatal morbidity and length of infant nursery stay were lower at BMC than at TJUH. The percentage of infants with one-minute Apgar scores less than 7 or requiring resuscitation at birth was greater at BMC, but the percentage of infants with five-minute Apgar scores less than 7 as well as neonatal mortality rates did not differ between the two institutions. The number of women with intrapartum or postpartum fever was too small to permit comparison. The study results suggest that care delivered at BMC is safe with regard to the evaluative criteria used.

Age of presentation in developmental disability.

ABSTRACT. It has not been determined whether severity of handicap or other associated factors are more important in determining the age of presentation for developmental disabilities. The relationship between age at presentation and referral source, presenting complaint, diagnosis, and associated factors (medical illness, motor signs, or behavioral disturbances) was examined in 738 consecutive children referred for developmental evaluation during 1982–1983. The nature of the complaint or diagnosis (motor, language, behavioral, or educational) was a far better predictor of age of presentation than the severity of the disorder. The degree of mental retardation did not affect age of presentation. Behavior problems did not affect the age of presentation for school failure or learning disability, but were associated with later presentation for motor delay, language delay, communication disorder, and within all IQ groups. The association of topography of handicap rather than severity with age of presentation should be considered when establishing or evaluating efforts at early identification of developmental disability.

A Comparison Of Visits And Practices Of Nurse‐Midwives And Obstetrician‐Gynecologists In Ambulatory Care Settings

With more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to womens health care in the United States. The objective of this study was to describe ambulatory visits and practices of CNMs, and compare them with those of obstetrician-gynecologists (OB/GYNs). Sources of population-based data used to compare characteristics of provider visits were three national surveys of CNMs and two National Ambulatory Medical Care Surveys of physicians. When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to OB/GYNs in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. The majority of visits to CNMs were for maternity care; the majority of visits to OB/GYNs were for gynecologic and/or family planning concerns. Face-to-face visit time was longer for CNMs, and involved more client education or counseling. This population-based comparison suggests that CNMs and OB/GYNs provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. Enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable.

Characteristics of nurse-midwife patients and visits, 1991.

OBJECTIVES This study describes the patient populations served by and visits made to certified nurse-midwives (CNMs) in the United States. METHODS Prospective data on 16,729 visits were collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling. RESULTS We estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits. CONCLUSIONS Nurse-midwives substantially contribute to the health care of women nationwide, especially for vulnerable populations.

Variations in pregnancy outcomes and use of obstetric procedures in two institutions with divergent philosophies of maternity care

Pregnancy outcomes were compared between a stratified random sample of 796 women delivering a live birth at a maternity center (BMC) and a frequency matched sample of 804 women delivering a live birth at a tertiary hospital (TJUH) in 1977–1978. The relationship of use of obstetric procedures with pregnancy outcomes was investigated within and between the two samples. The neonatal morbidity rate, as measured by Hobels neonatal risk score, was significantly higher and mean birth weights were lower at TJUH than at BMC when adjusted for institutional differences in use of obstetric procedures, medical-obstetric risk, and demographic characteristics. Conversely, the proportion of newborns with low 1-minute Apgar scores (fewer than seven) was significantly greater at BMC. The relationship of use of obstetric procedures with each outcome varied between the two institutions as well as across the three measures of pregnancy outcomes. The relationship of use of some procedures with each outcome may be explained in part by use of the procedure because of a suspected poor outcome of pregnancy, rather than an elevated risk of poor outcomes because of use of the procedure. Self-selection of some patients to BMC cannot be ruled out as a possible explanation for institutional differences.

Giftedness: Can it be Predicted in Infancy?

A cohort of 200 children, who were followed from birth and periodically evaluated as part of a longitudinal study of child development, was used to determine the ability of the Bayley Scales of Infant Development (BSID) to predict children who would be considered intellectually gifted at 7.5 years. The cohort was predominantly white (91%), upper middle class (70% in Hollingshead class 1 or 2), and had preschool educational experiences (94%). At outcome, 36 children had WISC-R verbal, performance, or full scale IQs greater than 135 and were called gifted. On average, gifted children walked 0.7 months earlier and spoke two-word sentences 2.2 months earlier than the non-gifted group. As a group, gifted children showed statistically significant, but clinically small, advantages for age of walking, age of speaking two-word sentences, BSID, and Stanford Binet IQ. Of the 36 children who later proved to be gifted, only two had BSID IQs greater than 134. Of the four children who had BSID IQs greater than 134, two maintained their superior function but 2 did not. A discriminant function analysis was used to predict giftedness for individual children based on BSID performance. The resulting classification achieved sensitivity = 0.69 and specificity = 0.39. Although groups of infants who will be gifted have higher BSID scores, the BSID cannot be endorsed as a method of identifying individual infants who will later demonstrate superior cognitive function.A cohort of 200 children, who were followed from birth and periodically evaluated as part of a longitudinal study of child development, was used to determine the ability of the Bayley Scales of Infant Development (BSID) to predict children who would be considered intellectually gifted at 7.5 years. The cohort was predominantly white (91%), upper middle class (70% in Hollingshead class 1 or 2), and had preschool educational experiences (94% ). At outcome, 36 children had WISC-R verbal, performance, or full scale IQs greater than 135 and were called gifted. On average, gifted children walked 0.7 months earlier and spoke two-word sentences 2.2 months earlier than the non-gifted group. As a group, gifted children showed statistically significant, but clinically small, advantages for age of walking, age of speaking two-word sentences, BSID, and Stanford Binet IQ. Of the 36 children who later proved to be gifted, only two had BSID IQs > 134. Of the four children who had BSID IQs > 134, two maintained their superior function but 2 did not. A discriminant function analysis was used to predict giftedness for individual children based on BSID performance. The resulting classification achieved sensitivity = 0.69 and specificity = 0.39. Although groups of infants who will be gifted have higher BSID scores, the BSID cannot be endorsed as a method of identifying individual infants who will later demonstrate superior cognitive function.

Follow-up Study of 105 Patients Who Left Treatment

Attention is focused in this chapter on 105 patients who left the six methadone maintenance programs after their first interview and who were reinterviewed in the community a year later. Before discussing the findings from this follow-up study, it is pertinent to address the issue of retention in methadone maintenance treatment.