Mary J. Ward

Outcomes 5 years after response to rituximab therapy in children and adults with immune thrombocytopenia.

Treatments for immune thrombocytopenic purpura (ITP) providing durable platelet responses without continued dosing are limited. Whereas complete responses (CRs) to B-cell depletion in ITP usually last for 1 year in adults, partial responses (PRs) are less durable. Comparable data do not exist for children and 5-year outcomes are unavailable. Patients with ITP treated with rituximab who achieved CRs and PRs (platelets > 150 × 10(9)/L or 50-150 × 10(9)/L, respectively) were selected to be assessed for duration of their response; 72 adults whose response lasted at least 1 year and 66 children with response of any duration were included. Patients had baseline platelet counts < 30 × 10(9)/L; 95% had ITP of > 6 months in duration. Adults and children each had initial overall response rates of 57% and similar 5-year estimates of persisting response (21% and 26%, respectively). Children did not relapse after 2 years from initial treatment whereas adults did. Initial CR and prolonged B-cell depletion predicted sustained responses whereas prior splenectomy, age, sex, and duration of ITP did not. No novel or substantial long-term clinical toxicity was observed. In summary, 21% to 26% of adults and children with chronic ITP treated with standard-dose rituximab maintained a treatment-free response for at least 5 years without major toxicity. These results can inform clinical decision-making.

Methylphenidate Administration to Juvenile Rats Alters Brain Areas Involved in Cognition, Motivated Behaviors, Appetite, and Stress

Thousands of children receive methylphenidate (MPH; Ritalin) for attention deficit/hyperactivity disorder (ADHD), yet the long-term neurochemical consequences of MPH treatment are unknown. To mimic clinical Ritalin treatment in children, male rats were injected with MPH (5 mg/kg) or vehicle twice daily from postnatal day 7 (PND7)–PND35. At the end of administration (PND35) or in adulthood (PND135), brain sections from littermate pairs were immunocytochemically labeled for neurotransmitters and cytological markers in 16 regions implicated in MPH effects and/or ADHD etiology. At PND35, the medial prefrontal cortex (mPFC) of rats given MPH showed 55% greater immunoreactivity (-ir) for the catecholamine marker tyrosine hydroxylase (TH), 60% more Nissl-stained cells, and 40% less norepinephrine transporter (NET)-ir density. In hippocampal dentate gyrus, MPH-receiving rats showed a 51% decrease in NET-ir density and a 61% expanded distribution of the new-cell marker PSA-NCAM (polysialylated form of neural cell adhesion molecule). In medial striatum, TH-ir decreased by 21%, and in hypothalamus neuropeptide Y-ir increased by 10% in MPH-exposed rats. At PND135, MPH-exposed rats exhibited decreased anxiety in the elevated plus-maze and a trend for decreased TH-ir in the mPFC. Neither PND35 nor PND135 rats showed major structural differences with MPH exposure. These findings suggest that developmental exposure to high therapeutic doses of MPH has short-term effects on select neurotransmitters in brain regions involved in motivated behaviors, cognition, appetite, and stress. Although the observed neuroanatomical changes largely resolve with time, chronic modulation of young brains with MPH may exert effects on brain neurochemistry that modify some behaviors even in adulthood.

Seductive Behavior of Mothers of Toddlers: Occurrence, Correlates, and Family Origins

SROUFE, L. ALAN, and WARD, MARY J. Seductive Behavior of Mothers of Toddlers: Occurrence, Correlates, and Family Origins. CHILD DEVELOPMENT, 1980, 51, 1222-1229. As part of a longitudinal study of lower-SES mothers and children through the first 5 years of life, measures of limit setting and control in a toy cleanup situation were developed. Of particular interest were a group of techniques including certain forms of sensual physical contact, sensual teasing, promises of affection, and maternal requests for affection. This category of behavior was reliably coded. In a sample of 173 mothers, 16 (9.25%) exhibited 1 or more of these behaviors. Several findings suggested a distinction between this seductive behavior and warmth or affection: (1) the behavior was directed almost exclusively to males (15 of 16); (2) it was associated with significantly more physical punishment and threats of punishment; (3) it was not related to cooperation, encouragement, or emotional support; and (4) in general, in both this context and a tool-problem situation, these 16 mothers were rated as less supportive and less effective in guiding their children than other mothers in the total sample, other mothers of boys, or mothers showing affection. Independent interviews with 36 mothers, including 8 mothers exhibiting seductive behavior, revealed clearly different family histories. The developmental implications of this pattern of maternal behavior are discussed.

Attachment and psychopathology in a community sample

Abstract The Structured Clinical Interview for DSM-III-R (SCID-I) and the Adult Attachment Interview (AAI) were administered to 60 women participating in a study (n = 226) of mother – child interaction. These women were not referred to the study for psychiatric care. The 60 women interviewed with the AAI were selected from the first 190 women who completed the SCID-I, so that 30 received a diagnosis and 30 did not. Analyses indicated that psychopathology diagnoses were associated significantly with mental representations of attachment classified in the AAI. The non-autonomous groups had increased likelihood of SCID diagnosis, compared to the autonomous group. While 32% of women with autonomous AAI transcripts received SCID diagnoses, 63% of women with Dismissing, 100% of woman with Preoccupied, and 65% of women with Unresolved transcripts received diagnoses. Secondary analyses indicated that Dismissing classifications were associated with Axis I diagnoses and Preoccupied classifications with affective disorders. Of note was that among women with Unresolved classifications, underlying secure attachment was associated with low risk of psychopathology, while underlying anxious attachment was associated with elevated risk of diagnosis. These findings support the premise from attachment theory that early relationships affect patterns of interpersonal expectations and behavior and affect regulation.

Role of the mother's touch in failure to thrive: a preliminary investigation.

OBJECTIVE This study investigated the hypothesis that specific types of maternal touch that might promote infant growth are reduced in cases of failure to thrive (FTT) and tested reports that maternal physical interaction and physical affection are diminished in FTT. METHODS Frequencies of operationally defined maternal touch categories were scored by blinded raters from videotaped mother-child feeding and play interactions of 21 children, aged 9 to 19 months, with FTT and 18 normally growing comparison children. After scoring and statistical analyses were completed, investigators unblinded to group status and clinical data reviewed the videotapes of the dyads with the lowest touch scores. RESULTS Mothers of children with FTT provided less matter-of-fact touch in feeding (p = .017) and unintentional touch in play (p = .048) than the comparison group, and there was a trend (p = .082) for them to provide less proprioceptive stimulation in play. Unblinded case reviews indicate that, among children with FTT, extremely infrequent touch signals a marked touch aversion by either the mother or child. CONCLUSIONS Types of maternal touch that may promote growth or facilitate feeding are reduced in FTT, due, in extreme cases, to maternal or child touch aversion. Clinicians evaluating FTT should be alert to very infrequent touch in the mother-child interaction and consider whether it may represent a maternal intolerance of physical contact with her infant or a problem with the infants feeding competence.

Disturbances of Affect Expression in Failure-to-Thrive

Positive and negative affects were assessed in 28 6- to 36-month-old children with failure-to-thrive and 14 normally growing children in feeding and nonfeeding situations. The roles of malnutrition and severity of organic effects also were examined. Failure-to-thrive children expressed less positive affect in the feeding and nonfeeding situations and more negative affect in feeding than normally growing children. Among failure-to-thrive children, the presence of both acute and chronic malnutrition was associated with heightened negative affect during feeding, whereas the degree of organic contribution had no effect. These results, if replicated, may have implications for clinical assessment and are discussed in terms of current theories of failure-to-thrive.

Intergenerational benefits of family-based HIV interventions.

The longitudinal impact of a family-based intervention on grandchildren of parents with HIV (PWH) is evaluated. Because PWH and their daughters demonstrated gains over 6 years when randomized to a coping skills intervention compared with a control condition, the adjustment of the PWHs grandchildren was also compared across conditions. Grandchildren in the intervention condition reported significantly fewer internalizing and externalizing behavioral symptoms compared with grandchildren in the control condition. There is weak evidence that grandchildren in the intervention condition had higher scores on measures of cognitive development and more positive home environments. These results suggest that there are possibly long-term, intergenerational benefits of an intervention for families coping with HIV.

Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers.

ABSTRACT Disorganized/Disoriented (D) attachment has seen widespread interest from policy makers, practitioners, and clinicians in recent years. However, some of this interest seems to have been based on some false assumptions that (1) attachment measures can be used as definitive assessments of the individual in forensic/child protection settings and that disorganized attachment (2) reliably indicates child maltreatment, (3) is a strong predictor of pathology, and (4) represents a fixed or static “trait” of the child, impervious to development or help. This paper summarizes the evidence showing that these four assumptions are false and misleading. The paper reviews what is known about disorganized infant attachment and clarifies the implications of the classification for clinical and welfare practice with children. In particular, the difference between disorganized attachment and attachment disorder is examined, and a strong case is made for the value of attachment theory for supportive work with families and for the development and evaluation of evidence-based caregiving interventions.

The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives

Phenomenon: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier. Approach: The purpose of this study is to describe pediatric residents’ experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach. Findings: Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees’ MH knowledge and skills to provide optimal MH care for children.

The Association between Childhood Overweight and Reflux Esophagitis

Background. In adults, it has been shown that obesity is associated with gastroesophageal reflux disease (GERD) and GERD-related complications. There are sparse pediatric data demonstrating associations between childhood overweight and GERD. Objective. To investigate the association between childhood overweight and RE. Methods. We performed a retrospective chart review of 230 children (M : F = 114  : 116) who underwent esophagogastroduodenoscopy (EGD) with biopsies between January 2000 and April 2006. Patient demographics, weight, height, clinical indications for the procedure, the prevalence of BMI classification groups, the prevalence of RE and usage of anti-reflux medications were reviewed. For these analyses, the overweight group was defined to include subjects with BMI≥ 85th percentile. The normal weight group was defined to include subjects with BMI 5th to 85th percentile. Results. Among the 230 subjects, 67 (29.1%) had BMI percentiles above the 85th percentile for age and gender. The prevalence of RE in the overweight group did not differ significantly from that in the normal weight group (23.9% versus 24.5%, resp.). Overweight subjects taking anti-reflux medications clearly demonstrated a higher prevalence of biopsy-proven RE compared to overweight subjects not taking anti-reflux medications (34.1% versus 7.7%, P = .009). Conclusions. There was no significant difference in the prevalence of biopsy-proven RE in the overweight group compared to the normal weight group. However, the prevalence of RE was significantly higher in overweight subjects on anti-reflux medications compared to overweight subjects not taking anti-reflux medications. This finding emphasizes the importance of early recognition and treatment of GERD for the overweight pediatric patients with symptoms in conjunction with weight loss program for this population to reduce long-term morbidities associated with GERD.