Ann Marie McCarthy

Posttraumatic stress disorder and physical comorbidity among female children and adolescents: Results from service-use data

Objective. In adults, posttraumatic stress disorder (PTSD) is associated with adverse health outcomes and high medical utilization and cost. PTSD is twice as common in women and is associated with increased risk for a range of diseases, chronic conditions, and reproductive-health problems. Little is known about the health effects of PTSD in children. The purpose of this study was to explore patterns of physical comorbidity in female children and adolescents with PTSD by using population data. Methods. This study was a cross-sectional, descriptive epidemiologic case-control analysis of a Midwestern states Medicaid eligibility and paid-claims data for girls (0–8 years old) and teens (9–17 years old). Data were from 1994–1997. All those with the PTSD diagnostic code were compared with randomly selected controls in relation to 3 sets of outcomes: (1) International Classification of Diseases, Ninth Revision (ICD-9) categories of disease; (2) chronic conditions previously associated with sexual trauma and PTSD in women; and (3) reproductive-health problems. Analyses included bivariate odds ratios (OR) and logistic-regression models that control for the extent of insurance coverage and the independent associations of victimization and psychiatric comorbidity with the 3 sets of outcomes. The mental health covariate was categorical to allow consideration of a range of severity. There were 4 categories for the young girls: neither PTSD nor depression, PTSD without depression, depression without PTSD, and PTSD + depression. For the adolescent analysis, a fifth category reflecting a “complex PTSD” was added, defined as having PTSD complicated by a dissociative disorder or borderline personality disorder diagnosis. Results. There were 647 girls and 1025 adolescents with the PTSD diagnosis. Overall, PTSD was associated with adverse health outcomes in both age strata. Victimization was sometimes independently associated with adverse health outcomes, but PTSD often was a mediator, especially in the adolescent age stratum. The importance of PTSD diagnosis as a predictor of the ICD-9 categories of disease or chronic conditions seemed to increase with age. In the younger age stratum, the increased bivariate ORs of significant associations with PTSD ranged from 1.4 for digestive disorders to 3.4 for circulatory disorders. Among younger girls, PTSD diagnosis was associated with significantly greater bivariate odds for 9 of the 12 ICD-9 categories of disease but not for neoplasms, blood disorders, or respiratory disorders and with threefold increased odds for chronic fatigue. They also had 1.8 times greater odds for sexually transmitted infections, some of which could be from congenital transmission in this age group, which includes infants. In the multivariate models for the young girls, the mental health variable seemed to mediate the relationship between victimization and increased odds of infectious and parasitic diseases, endocrine/metabolic/immune disorders, circulatory diseases, skin and cutaneous tissue disorders, and having any 1 of the 5 chronic conditions. The mental health categories that were significantly associated with health outcomes varied across the conditions. There were no health outcomes in which the depression-without-PTSD category was the only one significantly associated with the outcome condition. Circulatory and musculoskeletal disorders were significantly associated with all 3 of the mental health categories. Having any 1 of the 5 chronic conditions was significantly associated only with simple PTSD (PTSD without depression). Genitourinary disorders and signs/symptoms/ill-defined conditions were significantly associated with both simple and comorbid PTSD. PTSD with comorbid depression, the most severe of the mental health categories in this younger age group, was the only category associated with the endocrine/metabolic/immune disorders and skin disorders outcomes. In the adolescent age stratum, the bivariate ORs significantly associated with PTSD ranged from 2.1 for blood disorders to 5.2 for irritable bowel syndrome. Adolescents with PTSD were nearly twice as likely to have a sexually transmitted infection and 60% more likely to have cervical dysplasia. However, their rate of pregnancy was lower (23% vs 31%), a one-fourth decreased odds. In the adolescent group, only 4 outcomes (nervous system/sense organ, digestive, and genitourinary disorders and signs/symptoms/ill-defined conditions) remained statistically significantly associated with victimization after the mental health variable was added, suggesting an additive model of risk for these outcomes but a mediating role for PTSD in relation to the majority of the health outcomes. Among the adolescent girls, the range of ORs for the ICD-9 and chronic-condition diagnoses generally increased across the categories of the mental health variable in a dose-response pattern. Compared with adolescents with neither PTSD nor depression, those with PTSD without depression had statistically significant ORs from 1.5 to 3.6. Those with depression without PTSD had statistically significant ORs from 1.9 to 4.4. The significant ORs for those with PTSD comorbid with depression were from 2.3 to 6.6, and those in the complex-PTSD category had significant ORs of between 2.5 and 14.9. Only blood disorders seemed to be more strongly associated with depression alone than with the comorbid and complex forms of PTSD. The simple-PTSD category was not significantly associated with blood disorders, chronic pelvic pain, fibromyalgia, or dysmenorrhea. Depression without PTSD was not significantly associated with chronic pelvic pain or fibromyalgia. Fibromyalgia was only significantly associated with complex PTSD. Conclusions. In young girls who receive Medicaid benefits, PTSD was associated with increased odds of a range of adverse health conditions. The pattern and odds of physical comorbidity among adolescent recipients with PTSD was nearly as extensive as that seen in adult women. Overall, the pattern observed suggests that objective disease states (eg, circulatory problems, infections) may be associated with PTSD to an extent nearly as great as that of PTSD with more subjective somatic experience of loss of wellness. Using the concepts of allostatic load and allostatic support, professionals who work with children and adolescents may be able to decrease the toll that traumatic stress takes on health even if available interventions can only be thought of as supportive and fall short of completely preventing trauma exposure or completely healing posttraumatic stress. Clinical research to extend these exploratory findings is warranted.

Intervention research in highly unstable environments

This article highlights issues and presents strategies for conducting intervention research in highly unstable environments such as schools, critical care units, and long-term care facilities. The authors draw on their own experiences to discuss the challenges that may be encountered in highly unstable settings. The concept of validity provides a framework for understanding the value of addressing the many methodological issues that can emerge in settings characterized by instability. We explain unstable environments by elaborating on knowable elements that contribute to instability. Strategies are provided for improving success of intervention research in unstable settings by carrying out an environmental assessment prior to beginning a study.

Evidence-Based Practice and School Nursing.

School nurses need to demonstrate that their practice is based on the best evidence available, which is usually data obtained from research. Evidence-based practice involves combining the best evidence available with nursing expertise and patient and family preferences to determine optimum care. Evidence-based practice guidelines are developed by carefully reviewing the available evidence on a topic and synthesizing this information into recommendations for practice. This article defines evidence-based practice and best evidence, describes the development of evidence-based practice guidelines, discusses factors that affect the use of research and evidence-based practice guidelines in school nursing, and reviews current sources of evidence-based practice guidelines for school nurses. Strategies that school nurses can use to incorporate evidence into their practice are discussed. One recommendation is that school nurses partner with nurse leaders and nurse researchers to develop evidence-based practice guidelines relevant to school nurse practice.

Normative salivary cortisol values and responsivity in children

This was a descriptive study on normative salivary cortisol values and responsivity to a hospital clinic visit and an intravenous (IV) procedure in children. The study presented was a subproject of a primary research study that examined parents coaching their children requiring an IV placement in the use of distraction. One measure of child response in the primary study, salivary cortisol, was included to further our understanding of childrens physiologic response to stressful and painful stimuli. Salivary cortisol samples were obtained from 384 children aged between 4 and 10 years upon arrival to the clinic and 20 minutes after their IV insertion. Baseline samples were collected at home on a typical day for the children. Data from baseline samples were used to establish normative values between 8:00 a.m. and 3:00 p.m. on a nonprocedural day. Results demonstrate that normative cortisol levels in children follow a pattern similar to the circadian pattern in adults, decreasing from early morning to mid afternoon. Matched samples from control group children were used to evaluate group responsivity. Salivary cortisol levels on the baseline day were lower than those obtained during the day of the procedure and tapered over time as expected (-8.7% +/- 6.7%, p = .431). Cortisol levels on the clinic day increased from baseline and increased further in response to IV placement (15.7% +/- 6.7%, p = .023). A Location x Time interaction was significant (p = .019). Findings demonstrate that salivary cortisol is a useful measure of stress response that can be used to evaluate intervention effectiveness.

The Impact of Maternal Smoking during Pregnancy on Early Child Neurodevelopment

Early child neurodevelopment has major impacts on future human capital and health. However, not much is known about the impacts of prenatal risk factors on child neurodevelopment. We evaluate the effects of maternal smoking during pregnancy on child neurodevelopment between 3 months and 24 months of age and interactions with socioeconomic status (SES). We employ data from a unique sample of children from South America. Smoking has large adverse effects on neurodevelopment, with larger effects in the low-SES sample. Our results highlight the importance of early interventions beginning before and during pregnancy for enhancing child development and future human capital attainment.

Children with chronic conditions: Educators' views

The purpose of this qualitative, exploratory study was to identify the concerns and resource needs of educators for effectively teaching children with chronic health conditions, Semistructured audiotaped telephone interviews were conducted with 23 teachers and six principals from urban and rural public schools, grades K-12. The interview included questions in four areas: (a) experiences with children with chronic health conditions, (b) concerns in providing educational services to these children, (c) resources used by educators, and (d) recommendations regarding how information and services can best be provided to educators. The most common concerns were unanticipated medical emergencies and increased absence rates. The major resource for these educators was the school nurse. Educators preferred information specific to a child in their class, provided to them by the school nurse. Results suggest that interventions for teachers are more likely to be effective when they are coordinated with the school nurse and focus on the impact of the condition on a childs ability to function in the classroom. Subsequent research is necessitated to determine effective strategies for specialty nurses to aid school nurses in providing optimum care for these children.

Impact of parent-provided distraction on child responses to an IV insertion

This study evaluates the impact of parent-provided distraction on childrens responses (behavioral, physiological, parent, and self-report) during an IV insertion. Participants were 542 children, 4 to 10 years old, randomized to an experimental group that received a parent distraction coaching intervention or to routine care. Experimental group children had significantly less cortisol responsivity (p = .026). Children that received the highest level of distraction coaching had the lowest distress on behavioral, parent report, and cortisol measures. When parents provide a higher frequency and quality of distraction, children have lower distress responses on most measures.

Nursing interventions used in school nursing practice

School nurses need to define clearly their practice and identify the interventions they provide to students, families, and school employees. The purpose of this research was to identify which nursing interventions listed in Nursing Interventions Classification (NIC) are used by school nurses. Of the 174 surveys mailed to school nurses, 78 usable surveys were returned, representing a 45% return rate. Of the 433 NIC interventions, 114 were used by school nurses at least monthly, with 32 of these 114 interventions identified as being used at least once a week.

Cognitive behavioral pain and anxiety interventions in pediatric oncology centers and bone marrow transplant units

Although research conducted on the treatment of pain and anxiety in children has found a number of cognitive behavioral interventions to be effective, it is not known to what extent this research has been put into practice. The purpose of this project was to obtain information on the use of cognitive behavioral interventions to help children and families cope with the pain and anxiety experienced during lumbar punctures and bone marrow aspirations. In this descriptive study, 15 Pediatric Bone Marrow Transplant Units and 32 Pediatric Hematology/Oncology Centers from across the country were surveyed using a questionnaire developed to obtain information on the use and effectiveness of cognitive behavioral interventions and the availability of support services. This survey indicates that most centers use a number of cognitive behavioral interventions to help children cope with painful procedures. However, some interventions, such as providing information before procedures and positive reinforcement after procedures, are used more frequently than interventions, such as rhythmic breathing, distraction, and imagery, that require more time and training. A variety of support services were available, although psychological services were primarily available on an as needed basis and support groups were not usually offered on an ongoing basis. In general, nurses are the major providers of these interventions, with other professionals providing interventions specific to their training. Nurses need to continue to study appropriate ways to incorporate use of effective cognitive behavioral interventions into the routine care of children with cancer.

A healthy lifestyle program: promoting child health in schools

The problem of overweight children is an increasing public health concern in the United States. Many children today consume diets that are high in fat, lack regular physical activity, and receive minimal amounts of nutrition education at school. School-based education about nutrition and healthy lifestyles provides an opportunity for intervention with all children. A program for 4th- and 5th-grade students was designed to increase the student’s knowledge about nutrition and healthy lifestyles. After implementation of the program, there was a significant increase in student knowledge of nutrition and healthy lifestyles as determined by a pretest and posttest evaluation. The results have implications for school nurses because childhood behaviors have such a profound impact on future adult lifestyle choices.