James A. Blackman

Emotional, Developmental, and Behavioral Health of American Children and Their Families: A Report From the 2003 National Survey of Children's Health

BACKGROUND. Recent childrens health surveys have documented a high prevalence of emotional, developmental, and behavioral problems among children. Data from the 2003 National Survey of Childrens Health provide new insights into these problems and their association with family function and community participation. These issues have become a current focus of the World Health Organization. METHODS. Answers to questions of interest from the 2003 National Survey of Childrens Health were reported using estimates and SEs of rates. Statistical comparisons of rates with χ2 tests at the 0.05 level were made when relevant. RESULTS. The most commonly diagnosed problems among children 6–17 years of age were learning disabilities (11.5%), attention-deficit/hyperactivity disorder (8.8%), and behavioral problems (6.3%); among preschoolers, speech problems (5.8%) and developmental delay (3.2%) were most common. One in 200 children was diagnosed with autism. In contrast, rates of parental concerns about emotional, developmental, or behavioral problems were much higher; for example, 41% of parents had concerns about learning difficulties and 36% about depression or anxiety. Children with developmental problems had lower self-esteem, more depression and anxiety, more problems with learning, missed more school, and were less involved in sports and other community activities. Their families experienced more difficulty in the areas of childcare, employment, parent-child relationships, and caregiver burden. CONCLUSIONS. The most recent National Survey of Childrens Health mirrored results of previous surveys regarding rates of diagnosed emotional, developmental, and behavioral problems, including an escalating diagnosis of autism among children. Reported rates of parental concerns about these problems were much higher, suggesting possible underdiagnosis of childrens problems. Children with chronic problems had diminished family functioning, more school absences, and less participation in community activities compared with other children. Their parents experienced more difficulty with childcare, employment, and parenting skills. A change in treatment emphasis is needed, away from an exclusive focus on a childs developmental and behavioral problems to one that addresses the impacts of these problems on the family and community participation. A new approach to the way these issues are addressed and managed has the potential to enhance the quality of life for a child, as well as the parents, and to produce more meaningful and tangible solutions to these complex and increasingly evident problems.

Developmental and behavioral comorbidities of asthma in children

Objective: Asthma is the most common chronic childhood illness. Treatment is typically focused on disease management rather than developmental and behavioral comorbidities that may affect quality of life or contribute to poor disease control. The purpose of this study was to explore the prevalence of developmental and behavioral comorbidities of asthma and the role of confounding socioeconomic factors. Methods: The first National Survey of Children’s Health was the data source for this study. Interviews with parents or guardians were conducted during 2003–2004 to ascertain the physical, emotional, and behavioral health of 102,353 randomly selected children ages 0–17 years. Associations were examined between asthma and rates of developmental and behavioral problems. Logistic regression was used to adjust for potential confounding effects of age, gender, race, income, and parent education on outcomes. Results: Children with asthma have higher rates of attention-deficit/hyperactivity disorder; diagnoses of depression, behavioral disorders, learning disabilities; and missed school days (all p < .0001). The more severe the asthma is, the higher the rates are of these problems. Children with asthma are bullied more commonly and are more likely to abuse drugs. When socioeconomic factors are controlled for, asthma significantly increases the odds of having developmental, emotional, and behavioral problems. Conclusions: Children with asthma, especially severe asthma, are at high risk of developmental, emotional, and behavioral problems. Asthma is independently associated with these problems, although socioeconomic disadvantage adds additional risk. Asthma treatment programs must acknowledge and address these comorbidities to achieve the best overall outcomes for children with this common chronic disease.

CLINICAL CORRELATES OF LINEAR GROVWH IN CHILDREN WITH CEREBRAL PALSY

The purpose of this cross‐sectional study was to determine correlates of linear growth in children with cerebral palsy (CP). 171 children with CP were measured and their charts reviewed, z scores were calculated for weight (Wz) and height (Hz). Hz correlated positively with Wz and head circumference, and negatively with age, the presence of spastic quadriplegia, non‐ambulation and seizures. The correlation between Hz and age was stronger when non‐ambulatory children were analysed separately. Multiple linear regression resulted in only Wz and age contributing significantly to the variance in stature as measured by Hz. These results provide preliminary evidence that nutritional status is a major correlate of growth in CP. The finding that linear growth worsens with age independent of nutrition suggests that other factors also influence growth in CP.

Long-term Cognition, Achievement, Socioemotional, and Behavioral Development of Healthy Late-Preterm Infants

OBJECTIVEnTo compare healthy late-preterm infants with their full-term counterparts from age 4 through 15 years for numerous standard cognitive, achievement, socioemotional, and behavioral outcomes.nnnDESIGNnProspective cohort study.nnnSETTINGnNational Institute of Child Health and Development Study of Early Child Care and Youth Development, 1991-2007.nnnPARTICIPANTSnA total of 1298 children (53 born at 34-36 weeks gestational age), and their families, observed from birth through age 15 years. None of the infants had major health problems before or immediately following birth, and all the infants were discharged from the hospital within 7 days.nnnMAIN EXPOSUREnPreterm status: children born late preterm (34-36 weeks) vs those born full term (37-41 weeks).nnnMAIN OUTCOME MEASURESnEleven standard outcomes measuring cognition, achievement, social skills, and behavioral/emotional problems using the Woodcock-Johnson Psycho-Educational Battery-Revised and the Child Behavior Checklist, administered repeatedly through age 15 years.nnnRESULTSnNo consistent significant differences were found between late-preterm and full-term children for these standard measures from ages 4 to 15 years. Through age 15 years, the mean difference of most of these outcomes hovered around 0, indicating, along with small confidence intervals around these differences, that it is unlikely that healthy late-preterm infants are at any meaningful disadvantage regarding these measures.nnnCONCLUSIONnLate-preterm infants born otherwise healthy seem to have no real burdens regarding cognition, achievement, behavior, and socioemotional development throughout childhood.

Mechanisms, Clinical Presentations, Injuries, and Outcomes From Inflicted Versus Noninflicted Head Trauma During Infancy: Results of a Prospective, Multicentered, Comparative Study

OBJECTIVE. Our goal was to conduct a prospective, multicentered, comparative study that would objectively verify and explain observed differences in short-term neurodevelopmental outcomes after inflicted versus noninflicted head trauma. METHODS. Children <36 months of age who were hospitalized with acute head trauma confirmed by computed tomography imaging were recruited at multiple sites. Extensive clinical data were captured prospectively, subjects were examined, cranial imaging studies were blindly reviewed, and caregivers underwent scripted interviews. Follow-up neurodevelopmental evaluations were completed 6 months after injury. Head-trauma etiology and mechanisms were categorized by using objective a priori criteria. Thereafter, subject groups with inflicted versus noninflicted etiologies were compared. RESULTS. Fifty-four subjects who met the eligibility criteria were enrolled at 9 sites. Of 52 surviving subjects, 27 underwent follow-up assessment 6 months after injury. Etiology was categorized as noninflicted in 30 subjects, inflicted in 11, and undetermined in 13. Compared with subjects with noninflicted head trauma, subjects with inflicted head trauma (1) more frequently experienced noncontact injury mechanisms, (2) sustained greater injury depth, (3) more frequently manifested acute cardiorespiratory compromise, (4) had lower initial Glasgow Coma Scale scores, (5) experienced more frequent and prolonged impairments of consciousness, (6) more frequently demonstrated bilateral, hypoxic-ischemic brain injury, (7) had lower mental developmental index scores 6 months postinjury, and (8) had lower gross motor quotient scores 6 months postinjury. CONCLUSIONS. Compared with infants with noninflicted head trauma, young victims of inflicted head trauma experience more frequent noncontact injury mechanisms that result in deeper brain injuries, cardiorespiratory compromise, diffuse cerebral hypoxia-ischemia, and worse outcomes.

Apolipoprotein E and brain injury: implications for children.

Children with brain injuries that are apparently similar in etiology, severity, and clinical management have striking differences in outcomes. There is increasing evidence that genetic factors may influence brain injury severity and outcome.1–4 Apolipoprotein E (apoE)** is a lipid transport protein abundantly present in cells in the brain. In addition to transporting lipids, apoE has other functions necessary for cell maintenance and repair. The gene for apoE exists in three alleles (ε2, ε3, and ε4). Strittmatter and colleagues found APOE ε4 to be an important predisposing factor for the development of Alzheimer’s disease.5 Subsequently, the ε4 allele was shown to convey vulnerability to worse outcome after traumatic brain injury and other neurological insults in adults. In this review we will present the epidemiology of APOE genotypes, the molecular biology of apoE, and the mechanisms by which APOE genotypes might influence brain injury and repair differently. We will summarize the studies of APOE in adults with brain injury and the limited, but thought-provoking, information regarding APOE in children.

Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment

Importance Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months’ corrected age. Objectives To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy–specific early intervention that should follow early diagnosis to optimize neuroplasticity and function. Evidence Review This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. Findings Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months’ corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months’ corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. Conclusions and Relevance Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

Dopamine agonist therapy in low-response children following traumatic brain injury

The objective of this study was to determine whether a dopamine agonist could improve mental status among children in a low-response state following traumatic brain injury. In an 8-week, prospective, double-blind, randomized trial, 10 children and adolescents ages 8 to 21 years ( = 16.7 years) with traumatic brain injury sustained at least 1 month previously and remaining in a low-response state (Rancho Los Amigos Scale level ≤ 3) received pramipexole or amantadine. Medication dosage was increased over 4 weeks, weaned over 2 weeks, and then discontinued. At baseline and weekly during the study, subjects were evaluated with the Coma Near Coma Scale, Western NeuroSensory Stimulation Profile, and Disability Rating Scale. Scores improved significantly from baseline to the medication phase on the Coma Near Coma Scale, Western NeuroSensory Stimulation Profile, and Disability Rating Scale (P < .005). The weekly rate of change was significantly better for all three measures on medication than off medication (P < .05). Rancho Los Amigos Scale levels improved significantly on medication as well (P < .05). There was no difference in efficacy between amantadine and pramipexole. No unexpected or significant side effects were observed with either drug. This clinical trial supports the benefit of two dopamine agonists in the restoration of functional arousal, awareness, and communication. These drugs can be helpful in accelerating eligibility for acute rehabilitation among children and adolescents who have sustained significant brain injuries. (J Child Neurol 2006;21:879—885; DOI 10.2310/ 7010.2006.00203).

Attention-deficit/hyperactivity disorder in preschoolers. Does it exist and should we treat it?

The diagnosis of ADHD in preschool-aged children is difficult. High activity level, impulsivity, and short attention span--to a degree--are age-appropriate characteristics of normal preschool-aged children. However, excessive levels of these characteristics impede successful socialization, optimal learning, and positive parent-child interaction. Environmental stressors, inadequate parenting skills, and other diagnoses such as oppositional defiant, posttraumatic stress, or adjustment disorders can mimic ADHD. Although labeling may be necessary to obtain services, the emphasis should be placed on symptom resolution, given the uncertainties of diagnostic accuracy in this age group. Deferring a specific diagnosis of ADHD until confounding issues are clarified should be considered. The evaluation of serious behavior problems in young children must include a comprehensive consideration of environmental, health, cognitive, educational, and behavioral interactions. Both assessment and intervention should focus on the interactions between the child and his or her environment to determine how they facilitate or hinder adaptive integration as both the child and surroundings change and evolve. Treatment invariably necessitates involvement of a child and family psychotherapist or counselor to address behavior management strategies as well as family dynamics, parental psychopathology, or life stress. Parents must understand that counseling is an essential component of treatment and that they must be active participants. Psychopharmacologic intervention may be appropriate in some instances, although conventional wisdom suggests caution in young children, given the limited information about safety and efficacy of many agents, especially in children younger than 3 years old. Stimulants appear to be safe in older preschool-aged children. Children started on medication should be monitored closely for both positive and negative effects. A double-blinded, placebo-controlled trial of medication is warranted in equivocal situations.

The use of dopamine enhancing medications with children in low response states following brain injury

Primary objective : The study examines the possible relationship between dopamine-enhancing medications and improvement of arousal and awareness in children during persistent low response states (Rancho Los Amigos Levels I, II and III). Research design : A retrospective review was conducted of 10 children enrolled in an existing clinical protocol. The Kluge Childrens Rehabilitation Center (KCRC) low response protocol provides a double baseline serial measure (A, A, B, B, B) design. Scores on the Western NeuroSensory Stimulation Profile (WNSSP) are the dependent variable. Methods and procedures : Ten children, mean age of 13.7 years low response state (30 days or more) who were treated with dopamine agonists. Co-morbid or iatrogenic influences were addressed or ruled out. Seven children had traumatic brain injury, one cerebral vascular accident, one anoxia and one encephalitis. Experimental intervention : On average, dopamine medications were started 52.9 days post-event. Main outcomes and results : Paired t -test of WNSSP scores before medications and on medications were significant at p = 0.03 (paired t -test). Also, the distributions of the slopes (rates of change of WNSSP scores over time) were significantly different in the pre-medication and medication phases (Paired T -test, p = 0.02). Random coefficient model comparison of individuals during pre- and medication phase response variability on WNSSP yielded F -test at p = 0.02. Conclusions : These results suggest a promising relationship between acceleration of recovery for some children in a low response state and administration of dopamine-enhancing medications.