Richard W. Olmsted

Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer

Hypnosis was compared with nonhypnotic behavioral techniques for efficacy in reducing pain and anxiety in 27 children and adolescents during bone marrow aspiration and in 22 children and adolescents during lumbar puncture. The patients and independent observers each rated (scale of 1 to 5) pain and anxiety during one to three procedures prior to intervention and one to three procedures with intervention. Prior to intervention for both groups, pain during bone marrow aspiration was rated as more severe (P less than 0.01) than pain during lumbar puncture. During bone marrow aspiration pain was reduced to a large extent by hypnosis (P less than 0.001) and to a smaller but significant extent by nonhypnotic techniques (P less than 0.01), and anxiety was significantly reduced by hypnosis alone (P less than 0.001). During lumbar puncture only hypnosis significantly reduced pain (P less than 0.001); anxiety was reduced to a large degree by hypnosis (P less than 0.001) and to a smaller degree by nonhypnotic techniques (P less than 0.05). Thus hypnosis was shown to be more effective than nonhypnotic techniques for reducing procedural distress in children and adolescents with cancer.

Antecedents of child abuse

The qualities of parents who batter their children have been determined by interviewing known abusers. Because most studies lack controls and because family characteristics may be changed by abuse, a prospective study was instituted. Fourteen hundred low-income mothers were interviewed in a prenatal clinic, and the characteristics of 23 reported for abuse within two years were compared to the characteristics of the remaining mothers. The predominant antecedents of child abuse were: unwanted pregnancy, aggressive tendencies, and aberrant childhood nurture in which disturbed family relationships were more important than outright abuse. Abusive mother had slightly less self-esteem. Factors which increased exposure between parents and children seemed to increase risk for abuse. In contrast to retrospective findings, abusive mothers did not differ in support available from others, age, education, isolation, family alcohol or drug problems, and expectations of child development.

Emotional adjustment of adolescents and young adults with cystic fibrosis

Twenty-seven adolescents and young adults with cystic fibrosis were studied to evaluate the phychological impact of this chronic illness. At first glance, most patients appeared to function adequately on a daily basis. However, four sources of psychological stress, leading to emotional disturbance, were identified: altered physical appearance causing distorted body images and denial of sexuality, strained interpersonal relationships resulting in isolation and mental strain, conflicts in upbringing, and increased awareness of the future and of death. Guidelines for the physician treating these young adults and their families include: (1) encouragement for greater involvement by the patients father; (2) assisting the mother to find outside interests and to allow more independence to the patient; (3) stressing communication about cystic fibrosis within the home; (4) emphasizing outside activity for each patient; (5) repeated discussions of the patients concerns while emphasizing his strengths; (6) anticipation of problems, specific to cystic fibrosis, such as sterility in males; and (7) encouragement of interpatient communication.

Biofeedback: A new modality in the management of children with fecal soiling

Fifty children and adolescents who had severe fecal incontinence associated with either imperforate anus surgery in infancy or longstanding functional constipation were given biofeedback training for the purpose of achieving anal sphincter control. Feedback was in the form of oscilloscope tracings which the children learned to produce by contracting small air-filled balloons positioned at the internal and external anal sphincters. Forty-seven of these patients learned to have voluntary bowel movements, and 30 eliminated soiling accidents completely during follow-up periods ranging from six months to three years.

Dermal fistulas of dental origin in children.

Summary Four cases of dermal fistulas of dental origin have been presented to bring this entity more clearly to the attention of pediatricians. This subject is poorly documented in pediatric writings and may be relatively unfamiliar to many pediatricians. A dermal fistula in the submandibular region in children presents a different diagnostic problem, and the differential diagnosis is reviewed. Inability to eradicate the fistula completely is not uncommon and, in some cases, is due to lack of recognition of its origin in diseased dentition. It has been emphasized that permanent cure of a fistula originating from a periapical dental abscess can be obtained only by removal of the infected dentition.

Home management of hyperkinetic children.

Six clinical programs and one controlled, experimental program are described in which parents of hyperkinetic children were trained to alleviate behavior problems in the home. Parents attended educational workshops in which basic general principles of behavior modification were taught. As a result of the training workshops, parents were able to achieve significant reductions in their childrens hyperactivity and in the severity of behavioral problems, as well as significant gains in their knowledge of behavior management. All gains were maintained at the time of follow-up assessments. Parent-training workshops are considered to be a useful adjunct to other services provided to the hyperkinetic child and his family.

Evaluating trauma team performance in a Level i trauma center: Validation of the trauma team communication assessment (TTCA-24)

BACKGROUND Nontechnical skills (NTS), such as team communication, are well-recognized determinants of trauma team performance and good patient care. Measuring these competencies during trauma resuscitations is essential, yet few valid and reliable tools are available. We aimed to demonstrate that the Trauma Team Communication Assessment (TTCA-24) is a valid and reliable instrument that measures communication effectiveness during activations. METHODS Two tools with adequate psychometric strength (Trauma Nontechnical Skills Scale [T-NOTECHS], Team Emergency Assessment Measure [TEAM]) were identified during a systematic review of medical literature and compared with TTCA-24. Three coders used each tool to evaluate 35 stable and 35 unstable patient activations (defined according to Advanced Trauma Life Support criteria). Interrater reliability was calculated between coders using the intraclass correlation coefficient. Spearman rank correlation coefficient was used to establish concurrent validity between TTCA-24 and the other two validated tools. RESULTS Coders achieved an intraclass correlation coefficient of 0.87 for stable patient activations and 0.78 for unstable activations scoring excellent on the interrater agreement guidelines. The median score for each assessment showed good team communication for all 70 videos (TEAM, 39.8 of 54; T-NOTECHS, 17.4 of 25; and TTCA-24, 87.4 of 96). A significant correlation between TTTC-24 and T-NOTECHS was revealed (p = 0.029), but no significant correlation between TTCA-24 and TEAM (p = 0.77). Team communication was rated slightly better across all assessments for stable versus unstable patient activations, but not statistically significant. CONCLUSION TTCA-24 correlated with T-NOTECHS, an instrument measuring nontechnical skills for trauma teams, but not TEAM, a tool that assesses communication in generic emergency settings. TTCA-24 is a reliable and valid assessment that can be a useful adjunct when evaluating interpersonal and team communication during trauma activations. LEVEL OF EVIDENCE Diagnostic tests or criteria, level II.